The Canadian Veterinary Journal La Revue Vétérinaire Canadienne the Canadian Veterinary Journal La Revue Vétérinaire Canadie

March/Mars 2017March/Mars The Canadian Veterinary Journal

Vol. 58, No. 03 Vol. 58, La Revue vétérinaire canadienne

March/Mars 2017 Volume 58, No. 03

Semitendinosus myopathy and treatment with adipose-derived stem cells in working German shepherd police dogs

Prospective case-control study of toe tip necrosis syndrome (TTNS) in western Canadian feedlot cattle

Conceptualization of convenience euthanasia as an ethical dilemma for veterinarians in Quebec

Dexmedetomidine to control signs associated with lisdexamfetamine dimesylate toxidrome in a cat

Kidney injury in a dog following bee sting-associated anaphylaxis

Suspected bilateral phrenic nerve damage following a mediastinal mass removal in a 17-week-old pug

Computed tomographic and angiographic assessment of spinal extradural arteriovenous fistulas in a dog

Diagnosis and treatment of massive porcupine quill migration in a dog

Necrotizing hepatitis associated with Clostridium novyi in a pony in western Canada

Treatment of chronic sinusitis in a horse with systemic and intra-sinus antimicrobials

Significance of cytological smear evaluation in diagnosis of splenic mast cell tumor-associated systemic mastocytosis in a cat (Felis catus)

Experimental infection with Mycobacterium avium subspecies paratuberculosis resulting in decreased body weight in Holstein-Friesian calves

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MARCH/MARS 2017 Contents Table des matières

SCIENTIFIC RUBRIQUE SCIENTIFIQUE

ARTICLES 241 Semitendinosus myopathy and treatment with adipose-derived stem cells in working German shepherd police dogs Melissa A. Gibson, S. Gary Brown, Nancy O. Brown 247 Prospective case-control study of toe tip necrosis syndrome (TTNS) in western Canadian feedlot cattle Chad Paetsch, Kent Fenton, Tye Perrett, Eugene Janzen, Ted Clark, Jan Shearer, Murray Jelinski 255 Conceptualization of convenience 285 Necrotizing hepatitis associated with euthanasia as an ethical dilemma Clostridium novyi in a pony in western for veterinarians in Quebec Canada Dominick Rathwell-Deault, Béatrice Godard, Jennifer L. Davies, Francesco A. Uzal, Diane Frank, Béatrice Doizé Ashley E. Whitehead 289 Treatment of chronic sinusitis in a horse CASE REPORTS with systemic and intra-sinus antimicrobials RAPPORTS DE CAS Danielle L. Gordon, Catherine L. Radtke 261 Dexmedetomidine to control signs associated with lisdexamfetamine BRIEF COMMUNICATIONS dimesylate toxidrome in a cat COMMUNICATIONS BRÈVES Christopher L. Norkus, Iain Keir, Charlotte Means 293 Significance of cytological smear 265 Kidney injury in a dog following bee evaluation in diagnosis of splenic sting-associated anaphylaxis mast cell tumor-associated systemic Gareth James Buckley, Christopher Corrie, mastocytosis in a cat (Felis catus) Carsten Bandt, Michael Schaer Moges Woldemeskel, Anita Merrill, Cindy Brown 270 Suspected bilateral phrenic nerve damage 296 Experimental infection with Mycobacterium following a mediastinal mass removal avium subspecies paratuberculosis in a 17-week-old pug resulting in decreased body weight Mathieu Raillard, Pamela J. Murison, Ivan P. Doran in Holstein-Friesian calves 275 Computed tomographic and angiographic Gwendolyn L. Roy, Jeroen De Buck, Robert Wolf, Rienske A.R. Mortier, Karin Orsel, assessment of spinal extradural Herman W. Barkema arteriovenous fistulas in a dog Simona Morabito, Edoardo Auriemma, STUDENT PAPER Paolo Zagarella, Edy Mercuriali, Oriol Domenech, COMMUNICATION ÉTUDIANTE Gualtiero Gandini, Teresa Gagliardo, Eric Zini, Swan Specchi 299 Severe unilateral buphthalmos in a 4-month-old kitten 280 Diagnosis and treatment of massive Gillian Finnie porcupine quill migration in a dog Kathryn Flesher, Nathaniel Lam, Taryn A. Donovan 225 QUIZ CORNER TEST ÉCLAIR

CVJ / VOL 58 / MARCH 2017 211 FOR PERSONAL USE ONLY

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MARCH/MARS 2017 Contents Table des matières

FEATURES RUBRIQUES SPÉCIALES

PRESIDENT’S MESSAGE NOTICES ANNONCES LE MOT DU PRÉSIDENT 217 One Welfare/Un bien-être 284 Index of Advertisers Troy Bourque Index des annonceurs 309 Classifieds 221 VETERINARY MEDICAL ETHICS Petites annonces DÉONTOLOGIE VÉTÉRINAIRE

VETERINARY PRACTICE MANAGEMENT NEWS | NOUVELLES GESTION D’UNE CLINIQUE VÉTÉRINAIRE 303 Chasing higher wages: Associate veterinarian compensation through the 229 NEWS provinces/À la recherche de salaires NOUVELLES supérieurs : rémunération des vétérinaires Heather Broughton, Isabelle Vallières salariés dans les provinces Chris Doherty

307 DIAGNOSTIC OPHTHALMOLOGY OPHTALMOLOGIE DIAGNOSTIQUE Lynne S. Sandmeyer, Marina L. Leis, Bianca S. Bauer

Contributors

“Instructions for authors” are available online (www.canadianveterinarians.net). Les «Directives à l’intention des auteurs» sont disponibles en ligne (www.veterinairesaucanada.net).

CVJ / VOL 58 / MARCH 2017 213 FOR PERSONAL USE ONLY

The Canadian Veterinary Journal Editorial policy: All published articles including editorials and letters reflect the La Revue vétérinaire canadienne opinions of the authors and do not necessarily reflect the opinion of the publisher. Publication of an advertisement does not necessarily imply that the publisher agrees 339 rue Booth Street with or supports the claims therein. Ottawa, Ontario K1R 7K1 Politique de la Rédaction : Tous les articles publiés, y compris les éditoriaux et les Telephone: (613) 236-1162 lettres, représentent l’opinion de l’auteur et non pas nécessairement la position de Fax: (613) 236-9681 l’éditeur. E-mail: [email protected] La publication d’une annonce ne signifie pas nécessairement que l’éditeur est d’accord Website/Site Web: www.canadianveterinarians.net avec son contenu ou qu’il l’appuie. www.veterinairesaucanada.net Editor-in-Chief/Rédacteur en chef © C anadian Veterinary Medical Association 2017 Carlton Gyles, Guelph, Ontario L’Association canadienne des médecins vétérinaires 2017 Associate Editors/Rédacteurs associés Bruce Grahn, Saskatoon, Saskatchewan The Canadian Veterinary Journal is indexed or abstracted in: Wayne McDonell, Guelph, Ontario La Revue vétérinaire canadienne est indexée ou ses articles sont Feature Editors/Rédacteurs des chroniques résumés dans : Jangi Bajwa, Burnaby, British Columbia AGRICOL, Biological Abstracts, Capsule Report, Current Contents — Agriculture, Bruce Grahn, Saskatoon, Saskatchewan Derwent Veterinary Drug File, EMBASE/Excerpta Medica, Myrna Milani, Charlestown, New Hampshire Index Veterinarius, Index Medicus, Quarterly Index, Science Citation Index, Small Debbie Stoewen, Ayr, Ontario Animal Practice, Veterinary Bulletin, Veterinary Reference Service, Veterinary Update. Tim Blackwell, Fergus, Ontario Assistant Editors/Rédacteurs adjoints Photo by/Photo de : Shutterstock Robert Friendship, Guelph, Ontario Greg Harasen, Regina, Saskatchewan Typesetting/Typographie Jacob Thundathil, Calgary, Alberta AN Design Communications Ron Johnson, Guelph, Ontario Richard Kennedy, Pincher Creek, Alberta Printed by/Imprimé par Shawn McKenna, Charlottetown, P.E.I. The Lowe-Martin Group Ottawa, Ontario Managing Editor/Directrice de la rédaction Heather Broughton, Ottawa, Ontario ISSN 0008-5286 Assistant Managing Editor/Directrice adjointe de la rédaction Stella Wheatley, Ottawa, Ontario Return undeliverable Canadian addresses to: Editorial Coordinator/Coordonnatrice de la rédaction 339 rue Booth Street Linda Chow, Ottawa, Ontario Ottawa, Ontario K1R 7K1 e-mail: [email protected] Advertising Manager/Gérante de la publicité Laima Laffitte, Wendover, Ontario Subscriptions (2017). Annual: Canada $205 + applicable GST or HST; foreign $220 US; institutional $275. Express subscriptions available. Single issue/back issue: Published monthly by/ $25 each, institutional single issue = $50.00 + GST or HST, if applicable. (All prices Publication mensuelle de subject to change.) Missing issues will be replaced if the Subscriptions Office is Canadian Veterinary Medical Association notified within 6 months (for requests within Canada) and 1 year (for requests from abroad) of the issue date. The publisher expects to supply missing issues only when losses have been sustained in transit and when the reserve stock will permit. Telephone (613-236-1162) or (1-800-567-2862) and fax (613-236-9681) orders accepted with a valid Visa or MasterCard number. Please advise the publisher of address changes promptly. Abonnements (2017). Annuel : Canada 205 $ + TPS ou TVH en vigueur; pays étranger 220 $ É-U; prix d’une institution 275 $. Abonnement express disponible. Anciens numéros (chacun) : 25 $, ancien numéro d’institution 50 $ + TPS ou TVH en vigueur. Les prix sont sujets à changement sans préavis. Les numéros qui ne sont pas reçus seront remplacés si l’éditeur en est informée dans les 6 mois (pour les demandes venant du Canada) et 1 an (pour les demandes venant de l’étranger) suivant la date de parution. L’éditeur s’engage à remplacer les numéros manquants seulement lorsque les pertes ont été subies en transit et lorsque ses réserves le permettent. On peut payer son abonnement par téléphone (613-236-1162) ou (1-800-567-2862), par télécopieur (613-236-9681) ou par carte de crédit (Visa ou MasterCard). Veuillez aviser le bureau de l’éditeur de tout changement d’adresse.

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Abaxis_CVJ _0317.indd 1 2/7/17 9:59 AM FOR PERSONAL USE ONLY President’s Message Le mot du président

One Welfare Un bien-être

ne Health is by now a familiar concept. One Health has e concept d’Une seule santé est maintenant bien connu. Une O been part of the veterinary profession for many years; L seule santé fait partie de la profession depuis de nombreuses “One Health recognizes that the health of people is connected années. Les Centers for Disease Control and Prevention (CDC) to the health of animals and the environment. The goal of One définissent Une santé comme suit : «Une santé reconnaît que Health is to encourage the collaborative efforts of multiple la santé des personnes est reliée à la santé des animaux et de disciplines working locally, nationally, and globally to achieve l’environnement. Une santé a pour but d’encourager les efforts the best health for people, animals, and our environment” as concertés des nombreuses disciplines qui travaillent au niveau defined by the Centers for Disease Control and Prevention local, national et mondial afin d’assurer la meilleure santé possible (CDC). Veterinarians are, and have been, champions of One pour les humains, les animaux et notre environnement». Les Health using the concepts in daily practice. It is almost impos- médecins vétérinaires sont, et ont toujours été, les champions sible to discuss the concepts of One Health without considering d’Une seule santé car ils ont recours à ces concepts dans leur One Welfare. pratique quotidienne. Or, il est presque impossible de parler des One Welfare is an emerging term. Similar to One Health, concepts d’Une seule santé sans considérer Un bien-être. One Welfare looks at issues from a wider, national, global and Un bien-être est un nouveau terme. Comme Une santé, Un holistic perspective. The concept refers to not only animal bien-être aborde les enjeux d’un point de vue global qui est welfare but includes human welfare and societal mental health, aussi national, mondial et holistique. Le concept évoque non as well as environmental conservation. It uses One Health con- seulement le bien-être animal, mais il inclut aussi le bien-être cepts and ideas and applies them to welfare and environmental humain et la santé mentale sociétale ainsi que la conservation de issues. As veterinarians we are the leading advocates of animal l’environnement. Il fait appel aux concepts et aux idées d’Une welfare. We are also keenly aware of the positive effects animals seule santé et les appliquent ensuite aux enjeux liés au bien-être et have on humans such as companionship, food production, and à l’environnement. À titre de médecins vétérinaires, nous sommes biomedical research. We need as well to be aware of the interac- les premiers défenseurs du bien-être animal. Nous sommes aussi tions among animals, humans, and the environment and their pleinement conscients des effets positifs que les animaux ont sur impact on each other. les humains, notamment la compagnie, la production alimentaire Wellness and mental health in our profession is a major et la recherche biomédicale. Nous devons aussi être conscients des concern for the CVMA. We have unfortunately seen too many interactions entre les animaux, les humains et l’environnement et examples of serious mental health issues in our profession. de leur impact mutuel. Veterinary blogs, meetings, and conferences are full of well- Le bien-être et la santé mentale dans notre profession ness topics. Every provincial association offers some form of a représentent une préoccupation majeure de l’ACMV. Nous avons wellness program for its members. Mental health has become malheureusement vu trop d’exemples de graves problèmes de santé a major challenge for the profession. We, however, are not the mentale dans notre profession et les sujets de bien-être abondent only professionals dealing with mental health issues. Wellness is dans les blogues, les réunions et les conférences vétérinaires. a major concern for society in general. As veterinarians we also Toutes les associations provinciales offrent une certaine forme see mental health concerns with our clients and how that affects de programme de bien-être à leurs membres. La santé mentale the care of the animals under their control. Anyone who has had représente maintenant un défi majeur pour la profession. any experience with animal hoarding or poor farm animal living Cependant, nous ne sommes pas les seuls professionnels qui

Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.

CVJ / VOL 58 / MARCH 2017 217 FOR PERSONAL USE ONLY

conditions will know this all too well. Also many food animal One Welfare concepts. It’s great to see that many other schools practitioners can tell you the concerns about the environmental are following suit and providing veterinary services to low impact of intensive livestock operations and the need to address income society members, including the homeless population. them. When examining welfare it is natural to look at the bigger Just recently I read a news story about human homeless shelters picture and take a more holistic approach. accommodating pets. It is also fantastic to see societal natural One Welfare seems to be gaining momentum. An disaster plans that include animal evacuation protocols. Huge International One Welfare conference was held September success stories with One Health and One Welfare are emerg- 26 to 28th, 2016 in Winnipeg, Manitoba. The conference ing. Community Veterinary Outreach programs in Ottawa and provided national and international experts an opportunity to Toronto have been very successful, with thanks to driven indi- learn and collaborate on human and animal welfare concepts. viduals such as Dr. Michelle Lem and her colleagues. In addi- Things are happening at educational institutions as well. The tion, the CVMA Convention will feature a session on Remote Western College of Veterinary medicine (WCVM) has formed a Veterinary Care in Rural Canadian Communities and a panel LE MOT DU PRÉSIDENT DU MOT LE partnership with the department of psychology and has a social discussion on Accessible Veterinary Care. worker available for WCVM students as well as the clients of It is dificult to separate the welfare of an animal from the the teaching hospital and farm services. I have heard nothing health of an animal. Maybe the term One Health already means but positive feedback about this arrangement and suspect other One Welfare. Maybe we should start using One Health and One schools will follow the WCVM’s lead. The WCVM has also Welfare together when we discuss the concepts. Regardless, the developed a unique mentee education program that educates complex issues of human and animal welfare, and environmental students on how to be mentored and how mentorship works. conservation will only become more important in global society. This fits the holistic One Welfare concept. One Welfare will promote not only animal welfare but human The University of Calgary has developed a no-cost clinic for and societal well-being. ■ disadvantaged pet owners that has the dual benefit of helping the owners and their animals, and also aids in teaching students Troy Bourque

doivent composer avec des problèmes de santé mentale. Et le De plus, l’Université de Calgary a mis sur pied une clinique bien-être est une préoccupation majeure de la société en général. gratuite pour les propriétaires d’animaux défavorisés qui offre À titre de vétérinaires, nous pouvons aussi observer des problèmes le double avantage d’aider les propriétaires et leurs animaux et de santé mentale chez nos clients et la façon dont ils affectent qui facilite aussi l’enseignement des concepts d’Un bien-être aux les soins des animaux dont ils ont la garde. Quiconque a déjà étudiants. Il est positif de voir combien d’écoles emboitent le pas fait l’expérience de l’accumulation d’animaux ou de mauvaises et offrent des services vétérinaires aux membres à faible revenu conditions de vie des animaux de ferme connaîtra aussi trop bien de notre société, y compris la population de sans-abri. Tout ce fait. De plus, beaucoup de praticiens pour les animaux destinés récemment, je lisais un reportage sur les refuges pour les sans-abri à l’alimentation pourront vous communiquer leurs préoccupations qui accueillaient les animaux de compagnie. Il est aussi fantastique à propos de l’impact environnemental des opérations d’élevage de voir que les plans d’urgence en cas de catastrophes naturelles intensif ainsi que vous parler du besoin de les aborder. Lorsque de la société incluent des protocoles d’évacuation des animaux. nous examinons le bien-être, il est naturel d’envisager l’ensemble Nous prenons aussi connaissance de véritables histoires de réussite de la situation et d’adopter une approche plus holistique. de programmes d’Une santé et d’Un bien-être. Par exemple, les Un bien-être semble prendre de l’essor. Une conférence programmes de Community Veterinary Outreach à Ottawa et internationale sur Un bien-être s’est tenue du 26 au 28 septembre à Toronto ont connu un énorme succès, grâce à des personnes à Winnipeg, au Manitoba. La conférence a donné l’occasion motivées comme la Dre Michelle Lem et ses collègues. De plus, le aux experts nationaux et internationaux de se renseigner sur congrès de l’ACMV présentera un atelier sur les soins vétérinaires les concepts de bien-être humain et animal et de collaborer à à distance dans les collectivités rurales du Canada et un débat de des projets dans ce domaine. Les choses bougent aussi dans spécialistes sur les soins vétérinaires accessibles. les établissements d’enseignement. Le Western College of Il est difficile de séparer le bien-être d’un animal de la santé d’un Veterinary Medicine (WCVM) a formé un partenariat avec le animal. Peut-être que le terme Une santé signifie déjà Un bien-être. département de psychologie et un travailleur social est disponible Peut-être que nous devrions commencer à utiliser Une santé et Un pour les étudiants du WCVM ainsi que les clients de l’hôpital bien-être ensemble lorsque nous discutons les concepts. Ce qui est d’enseignement et des services agricoles. Tous les commentaires toutefois certain est que les enjeux complexes du bien-être humain que j’ai entendus à l’égard de ce programme ont été positifs et je et animal et de la conservation de l’environnement deviendront soupçonne que d’autres écoles suivront l’exemple du WCVM. Le de plus en plus importants dans la société mondiale. Un bien-être WCVM a aussi mis au point un programme d’éducation unique fera la promotion non seulement du bien-être animal mais aussi pour les mentorés qui enseigne aux étudiants comment interagir du bien-être des humains et de la société. ■ avec un mentor ainsi que les principes du mentorat. Signalons que ce programme s’insère dans le concept holistique d’Un bien-être. Troy Bourque

218 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY

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Ethical question of the month — March 2017 For the past several decades, veterinary school admissions have been weighted towards academic performance and a subjective assessment of how applicants respond to interview questions. Several studies indicate that this system for assessing applicants does not accurately predict clinical competency in the final year rotation. Other research suggests that practicing veterinarians are at an increased risk of severe stress in the workplace manifested by a higher risk of suicide and other negative health outcomes. Should systems for assessing applicants for admission to the veterinary curriculum be subjected to more outcome-based scrutiny in terms of competency, job satisfaction, and personal health? Could changes in applicant screening procedures risk breaching the basic principles of justice or the rights and freedoms articulated in the Canadian constitution? Submitted by Terry Whiting, Winnipeg, Manitoba Question de déontologie du mois — Mars 2017 Au cours des dernières décennies, l’admission à l’école de médecine vétérinaire s’est surtout appuyée sur les résultats scolaires et une évaluation subjective de la façon dont les candidats répondaient aux questions d’entrevue. Plusieurs études indiquent que ce système d’évaluation des candidats ne prédit pas bien les compétences cliniques lors des rotations de la dernière année du programme. D’autres études suggèrent que les vétérinaires praticiens s’exposent à un risque accru de stress aigu au travail qui se manifeste par une plus grande vulnérabilité au suicide et à d’autres problèmes de santé. Les systèmes d’évaluation devraient-ils soumettre les candidats à l’admission au programme vétérinaire à un examen qui se concentre sur les résultats en matière de compétence, de satisfaction à l’égard du travail et de santé personnelle? Ces changements aux procédures d’évaluation des candidats pourraient-ils risquer d’enfreindre les principes de base de la justice ou les droits et les libertés enchâssés dans la constitution canadienne? Soumise par Terry Whiting, Winnipeg (Manitoba)

Responses to the case presented are welcome. Please limit your Les réponses au cas présenté sont les bienvenues. Veuillez reply to approximately 50 words and forward along with your limiter votre réponse à environ 50 mots et nous la faire parvenir name and address to: Ethical Choices, c/o Dr. Tim Blackwell, par la poste avec vos nom et adresse à l’adresse suivante : 6486 E. Garafraxa, Townline, Belwood, Ontario N0B 1J0; Choix déontologiques, a/s du Dr Tim Blackwell, 6486, telephone: (519) 846-3413; fax: (519) 846-8178; e-mail: E. Garafraxa, Townline, Belwood (Ontario) N0B 1J0; [email protected]. téléphone : (519) 846-3413; télécopieur : (519) 846-8178; Suggested ethical questions of the month are also welcome! All courriel : [email protected]. ethical questions or scenarios in the ethics column are based Les propositions de questions déontologiques sont toujours on actual events, which are changed, including names, loca- bienvenues! Toutes les questions et situations présentées dans tions, species, etc., to protect the confidentiality of the parties cette chronique s’inspirent d’événements réels dont nous involved. modifions certains éléments, comme les noms, les endroits ou les espèces, pour protéger l’anonymat des personnes en cause.

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Ethical question of the month — December 2016 A “swine” client calls to report that a recent hire turned out to be an animal activist who placed disturbing videos on the Internet of another employee mishandling both sows and piglets. Major retailers immediately notified their suppliers that they would not accept pork from this farm. Your swine client reports that the employee in the video had behavioral problems that led to his dismissal shortly after he was hired. The client explained to the media that the employee was terminated and that the video does not reflect the farm’s stockmanship practices. Nevertheless retailers want to distance themselves from this disturbing video and are refusing to purchase his pork. As a result your client now has over-stocking problems as he waits for regulatory bodies to investigate. The client is calling to request that you euthanize healthy market hogs so he will not be accused of overcrowding his pigs. He wants the euthanasia done by a professional to ensure he is not in some way accused of further animal welfare infractions. You are concerned that euthanizing these healthy hogs will simply increase public displeasure but you cannot find a packer willing to accept the pigs. How should you respond? DÉONTOLOGIEVÉTÉRINAIRE Question de déontologie du mois — Décembre 2016 Un client «porcin» appelle pour signaler qu’un employé embauché récemment s’est révélé être un activiste de défense des animaux qui a publié des vidéos troublantes sur Internet qui montraient un autre employé maltraitant les truies et les porcelets. Les grands détaillants ont immédiatement avisé leurs fournisseurs qu’ils n’accepteraient pas la viande de porc provenant de cette ferme. Votre client porcin signale que l’employé dans la vidéo manifestait des problèmes de comportement qui ont causé son congédiement peu de temps après l’embauche. Le client a expliqué aux médias que l’employé avait été congédié et que la vidéo ne reflétait pas les pratiques d’élevage employées à la ferme. Néanmoins, les détaillants désirent se distancier de cette vidéo troublante et refusent d’acheter son porc. Par conséquent, votre client est maintenant aux prises avec des problèmes de surpeuplement en attendant l’enquête des organismes de réglementation. Le client vous appelle pour vous demander d’euthanasier des porcs de marché en santé afin qu’il ne soit pas accusé d’entasser ses porcs. Il désire que l’euthanasie soit faite par un professionnel afin qu’il ne soit pas accusé de nouvelles infractions liées au bien-être animal. Vous vous inquiétez que l’euthanasie de ces porcs en santé ne fera qu’accroître la grogne du public, mais vous ne pouvez pas trouver un abattoir disposé à accepter les porcs. Comment devriez-vous répondre?

An ethicist’s commentary on veterinarian asked to euthanize healthy hogs I have many times in this column quoted Plato as a source of to donate these animals, once processed, to a food bank or the good ethical wisdom. Once again, his pronouncements are Salvation Army or some other worthy charity making sure that relevant and timely to this current issue. Plato once remarked people have adequate food, particularly in holiday seasons. The that one should, if possible, “make a virtue of necessity.” This only problem, you should state, is finding a packer willing to is a more sophisticated variation on the common sense dictum process these animals. I think that we can be morally certain that that if life gives you lemons, make lemonade. the hitherto reluctant packers will fall all over themselves to do The client’s request for euthanasia is an extremely bad idea, so. I am also morally certain that, in the interest of good public both for him and for you. As you fear, killing these animals to relations, something packers do not usually enjoy, they will do no purpose will only further turn public opinion against the the job at minimal cost or indeed gratis. If, mirabile dictu, some client. In addition, doing so will harm your own reputation. demand payment, you are sure to find one that does not. The last thing any veterinarian wishes to be known for is killing This situation would represent a classic case of making a healthy animals for no purpose. virtue of necessity. Additionally, your client could sweeten the How then, can this dire scenario be turned into a positive pot by agreeing to make a similar, albeit smaller, donation each one? One relatively simple approach would be to get the local holiday season. Neither a producer nor a processor could buy media to cover the story, and thereby explain to the public that such a degree of favorable publicity, which could go a long way your client is not at all culpable for any animal abuse. Assuming to expunging the bad image created by the whole unfortunate that he was diligent in monitoring the behavior of his employees situation! Nor will such a tactical move on your part at all harm as a matter of course, he bears no guilt. Ideally, if he has any your image in the community. common sense whatsoever, he has instituted new safeguards to Using the media to advance a worthwhile cause is typically make sure this sort of abuse can never happen again, and these not a strategy often deployed by veterinarians. But all veteri- should be recounted in the story. Clearly, if he is willing to have narians understand, at some level, how effective it can be, for these hogs euthanized, financial considerations entailed by their example, in adopting out a dog that has been abandoned, hit loss does not loom large in his mind. Most important, certainly, by a car, or suffered some other fate that moves people to act. is the potential damage to his — and your — reputations. There is no shame in such actions; quite the contrary! In the newspaper story, it should be stressed that it would be sinful simply to discard these animals. Therefore, in talking to the reporter, you should emphasize that the client is willing Bernard E. Rollin, PhD

222 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY

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Quiz Corner Test éclair

1. A 12-year-old Chihuahua is presented for hair loss. 1. Un Chihuahua âgé de 12 ans est examiné à cause d’une perte Examination reveals a multifocal circular alopecia with de poils. L’examen révèle une zone multifocale d’alopécie evidence of papules and pustules, but no evidence of circulaire avec évidence de papules et de pustules, mais sans scratching. The skin of the abdomen is extremely thin with signe de prurit. La peau de l’abdomen est extrêmement mince abundant comedones and prominent blood vessels. Upon et les vaisseaux sanguins sont très apparents. Après un further questioning of the owner it is revealed that the questionnement plus poussé au propriétaire, on remarque patient has been urinating in the house and drinking que le chien urine dans la maison et qu’il boit des quantités increased amounts of water. Which of the following is d’eau plus grandes. Laquelle des épreuves suivantes est la plus the most appropriate test to confirm the most likely appropriée pour confirmer le diagnostic le plus probable? diagnosis? A. mesure de la concentration sérique de thyroxine (T4) totale; A. Serum total T4 concentration B. test de stimulation de l’hormone adrénocorticotrope (ACTH); B. Adrenocorticotropic hormone (ACTH) stimulation test C. mesure de la concentration du cortisol de base; C. Baseline cortisol concentration D. mesure de la concentration de l’hormone adrénocorticotrope D. Endogenous ACTH concentration (ACTH) endogène; E. Serum free T4 concentration by equilibrium dialysis E. mesure de la concentration sérique de la thyroxine (T4) libre par dialyse à l’équilibre. 2. A 3-year-old female saluki, apparently in good health, is seen for a prebreeding screen, and a serum sample is col- 2. Une chienne lévrier Saluki âgée de 3 ans, apparemment en lected for thyroid hormone measurement. Concentrations bonne santé, est examinée pour une évaluation avant of both total thyroxine [tetra-iodothyronine (T4)] and free l’accouplement et un échantillon de sérum est prélevé pour T4 are slightly below the canine reference ranges, and la mesure de l’hormone thyroïdienne. Les concentrations de thyroid-stimulating hormone concentration (TSH) is within la thyroxine totale (tétra-iodothyroxine [T4]) et de la normal limits. Thyroglobulin autoantibody measurement is thyroxine (T4) libre sont légèrement inférieures aux valeurs negative. Which of the following statements is correct? de référence canines et la concentration de la thyrotrophine A. The low thyroid hormone concentrations indicate hypo- (TSH) est dans les limites normales. La mesure de l’anticorps thyroidism, and this dog should be started on thyroid de la thyroglobuline est négative. Lequel des énoncés suivants replacement therapy. est correct? B. These concentrations are probably normal for this dog. A. Les faibles concentrations de l’hormone thyroïdienne C. This dog must have some underlying illness causing the indiquent de l’hypothyroïdisme et on doit débuter une suppression of thyroid hormone concentrations. thérapie de remplacement de la thyroïde chez cet animal. D. This dog has lymphocytic thyroiditis. B. Ces concentrations sont probablement normales pour cette E. Thyroid supplementation should be initiated, since the chienne. low thyroid hormones indicate that there will be problems C. Cette chienne doit souffrir de maladies sous-jacentes with breeding this dog. causant la suppression des concentrations de l’hormone thyroïdienne. 3. Radiographic evaluation of a 10-year-old cat strongly sug- D. Cette chienne souffre de thyroïdite lymphocytaire. gests osteosarcoma of the scapula. Which of the following E. On doit débuter l’administration d’un supplément de represents the most appropriate course of action? thyroïde puisque les faibles valeurs de l’hormone A. Radiation therapy followed by amputation of the scapula thyroïdienne indiquent qu’il y aura des problèmes à B. Chemotherapy accoupler cette chienne. C. Evaluation of serum alkaline phosphatase activity D. Thoracic radiographs for evaluation of metastasis

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4. Which of the following parameters is most appropriately 3. Un examen radiographique d’un chat âgé de 10 ans suggère used as a measure of performance in the commercial cow- fortement un ostéosarcome de la scapula. Laquelle des calf industry? mesures suivantes est la plus appropriée? A. Average daily gain A. radiothérapie suivie de l’amputation de la scapula; B. Percent choice quality grade B. chimiothérapie; C. Feed conversion C. examen de l’activité de la phosphatase alcaline sérique; D. Rolling herd milk production D. radiographies thoraciques pour permettre l’évaluation des E. Weaning percentage métastases. 5. Intravenous (IV) administration of therapeutic doses of lidocaine 4. Lequel des paramètres suivants est le plus approprié comme

TESTÉCLAIR is associated with which of the following effects in the horse? mesure de performance dans l’industrie commerciale A. Conversion of atrial fibrillation vache-veau? B. Analgesia A. gain de poids quotidien moyen; C. Reduction in the hematocrit B. pourcentage du classement de la qualité; D. Sedation C. conversion alimentaire; E. Excitement D. production laitière moyenne du troupeau; E. pourcentage du taux de sevrage. 5. L’administration intraveineuse de doses thérapeutiques de lidocaïne est associée à quel effet suivant chez le cheval? A. conversion de la fibrillation auriculaire; B. analgésie; C. diminution de l’hématocrite; D. sédation; E. excitation.

(See p. 279 for answers./Voir les réponses à la page 279.)

Questions and answers were derived from Review Questions and Answers for Veterinary Boards 2nd ed., a 5-volume series including Basic Sciences, Clinical Sciences, Small Animal Medicine and Surgery, Large Animal Medicine and Surgery, and Ancillary Topics, by kind permission of the publisher, Mosby–Year Book, Inc., St. Louis, Missouri.

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NEWS | NOUVELLES

March is National Tick Awareness Mars est le Mois national de la Month sensibilisation aux tiques Be prepared for the start of tick activity... Soyez prêts pour le début de l’activité des and an increase in ectoparasite control tiques... et une hausse des consultations consultations du contrôle des ectoparasites he arrival of March brings the promise of warmer weather, e mois de mars annonce la promesse de l’arrivée des Twith an increasing number of days above 4°C; the tempera- Ltempératures plus douces et d’un nombre grandissant de ture at which ticks become active. jours où le mercure dépassera 4 °C, la température à laquelle les This March also marks the start of the 2nd annual National tiques deviennent actives. Tick Awareness Month (NTAM), an initiative introduced in Ce mois de mars marque aussi le début de la deuxième édition 2016 by the Canadian Veterinary Medical Association (CVMA) annuelle du Mois national de la sensibilisation aux tiques (MNST), in partnership with Merck Animal Health. une initiative introduite en 2016 par l’Association canadienne des “Since last year’s inaugural campaign, we’ve started to see médecins vétérinaires (ACMV) en partenariat avec Merck Santé a change in the conversation. More and more pet owners are animale. beginning to realize the importance of early tick prevention,” «Depuis la campagne inaugurale de l’an dernier, nous avons says CVMA president, Dr. Troy Bourque. “That said, shifting commencé à observer un changement dans la conversation. De perceptions, letting go of ingrained habits, and embracing new plus en plus de propriétaires d’animaux commencent à réaliser ones can take time. National Tick Awareness Month provides l’importance de la prévention précoce des tiques», dit le président an ideal platform for us to continue to share the message and de l’ACMV, le Dr Troy Bourque. «Cela dit, le changement des build further momentum.” perceptions, l’abandon d’habitudes ancrées et l’adoption de Once again this year, the CVMA and Merck Animal Health nouvelles façons de faire peut prendre du temps. Le Mois national are providing the veterinary community with technical and de la sensibilisation aux tiques offre une plate-forme idéale pour client-communication NTAM support tools. nous permettre de continuer à communiquer le message et à NTAM launch webinar poursuivre sur cette lancée.» De nouveau cette année, l’ACMV et Merck Santé animale On March 1, 2017, Dr. Scott Stevenson, BMSc, MSc, DVM, fourniront des outils de soutien technique et de communication and Dr. Robbin Lindsay, BSc, MSc, PhD, took part in a live avec les clients lors du MNST. webinar during which they provided up-to-date information on the current tick situation and how veterinarians can help combat Webinaire de lancement du Mois national the growing threat of ticks and Lyme disease in Canada. de sensibilisation aux tiques This webinar is now available for on-demand streaming on Le 1er mars 2017, le Dr Scott Stevenson, B.M.Sc., M.Sc., D.M.V., et the CVMA website. Robbin Lindsay, B.Sc., M.Sc., Ph.D., ont participé à un webinaire Client-education tools en direct durant lequel ils ont communiqué les tout derniers renseignements sur la situation actuelle des tiques et sur la façon In light of veterinarians’ positive feedback, NTAM client- dont les vétérinaires peuvent contribuer à la lutte contre la menace communication material will be available to clinics again this grandissante présentée par les tiques et la maladie de Lyme au year. This material includes an in-clinic poster and an info- Canada. graphic poster, as well as ready-to-use social media posts that Ce webinaire est maintenant disponible sur demande pour can be cut and pasted to Facebook and/or Twitter, or used as diffusion en continu sur le site Web de l’ACMV. content on clinic websites. Outils pour l’éducation des clients À la lumière de la rétroaction positive des vétérinaires, de nouveau cette année, du matériel du MNST sera disponible pour permettre aux cliniques de communiquer avec les clients. Ce matériel inclura une affiche pour la clinique et une affiche infographique ainsi que des messages des médias sociaux prêts à utiliser qui peuvent être

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N Most clinics should have received the printed material by coupés et collés dans Facebook et/ou Twitter, ou utilisés comme now. More information, as well as download links and additional contenu dans les sites Web des cliniques. member-specific tools, are available on the CVMA website. La plupart des cliniques devraient maintenant avoir reçu le matériel imprimé. De plus amples renseignements, ainsi que des NEW in 2017: National Public Relations liens de téléchargement et des outils additionnels s’adressant aux Campaign membres, sont disponibles sur le site Web de l’ACMV. When veterinarians who took part in last year’s NTAM campaign were asked for suggestions of ways to help promote NTAM even DU NOUVEAU en 2017 : une campagne more effectively in 2017, increased media awareness was at the nationale de relations publiques top of their wish list. Lorsque l’on a demandé aux vétérinaires qui ont participé à la As a result, a “public service announcement” type of video campagne du MNST de l’an dernier de présenter des suggestions was produced to help increase dog owner awareness of the sur les façons de promouvoir le MNST plus efficacement en importance of early tick control, and to encourage clients to talk 2017, une sensibilisation accrue des médias se trouvait au haut to their veterinarian about the risk ticks may pose to their dog(s). de la liste. It will be promoted via an online advertising campaign in March. Par conséquent, une vidéo de type «message d’intérêt public» a This video, which has been publicly released to coincide été produite afin de rehausser la sensibilisation des propriétaires with NTAM, is also available to view on the CVMA website. de chiens à propos de l’importance d’un contrôle des tiques Veterinary clinics are encouraged to view and share the video précoce et d’encourager les clients à parler à leur vétérinaire à with their clients. propos des risques présentés par les tiques pour leurs chiens. On For more information on National Tick Awareness Month, fera la promotion de cette vidéo dans le cadre d’une campagne de and to access all NTAM resources — including the NTAM publicité en ligne en mars. launch webinar, in-clinic communication material, ready-to- Cette vidéo, qui a été diffusée publiquement afin de coïncider use social media posts, and the dog-owner awareness video avec le MNST, peut aussi être visualisée sur le site Web de l’ACMV. — please visit the CVMA website (www.canadianveterinarians. On encourage les cliniques vétérinaires à visualiser et à partager net/practice-economics/practice-tools-national-tick-awareness- la vidéo avec leurs clients. month). Pour en savoir davantage sur le Mois national de la sensibilisation aux tiques et pour accéder à toutes les ressources du MNST — dont le webinaire de lancement du MNST, le matériel de communication dans la clinique, des messages prêts à utiliser pour les médias sociaux et la vidéo de sensibilisation des propriétaires de chiens — veuillez visiter le site Web de l’ACMV (www.veterinairesaucanada.net/practice-economics/practice-tools- national-tick-awareness-month).

2017 CVMA Convention Congrès 2017 de l’ACMV Charlottetown, July 13–16 Charlottetown, du 13 au 16 juillet Unleash Your Potential! Libérez votre potentiel! ake a few minutes to flip through the CVMA Convention’s renez quelques minutes pour parcourir le programme TPreliminary Program (included with this month’s CVJ) Ppréliminaire du congrès de l’ACMV (qui est aussi inclus dans to familiarize yourself with the convention taking place in le présent numéro de La RVC) afin de vous familiariser avec le Charlottetown, Prince Edward Island, July 13–16. congrès qui se déroulera du 13 au 16 juillet à Charlottetown, à One of the unique features of the CVMA Convention is l’Île-du-Prince-Édouard. that it offers diverse wet labs. In collaboration with the Atlantic Le congrès de l’ACMV est unique en son genre car il présentera Veterinary College, a wide range of wet labs will be held on divers laboratoires de travaux pratiques. En collaboration avec Thursday, July 13. “Nerve Blocks and Tooth Extraction in l’Atlantic Veterinary College, un vaste éventail de laboratoires de Dogs and Cats” will be offered by Drs. Alex Reiter and Sue travaux pratiques sera présenté le jeudi 13 juillet. Le laboratoire McTaggart. The morning session is a basic level and the after- «Nerve Blocks and Tooth Extraction in Dogs and Cats» sera noon session is rated moderate to advanced. This workshop is présenté par les Drs Alex Reiter et Sue McTaggart. L’atelier sponsored by Serona Animal Health. du matin sera de niveau de base et l’atelier en après-midi sera An equine lab, “The Oral Examination: From Touching de niveau modéré à avancé. Ce laboratoire est commandité par and Feeling to Oral Endoscopy and Imaging” will be con- Serona Animal Health. ducted by Drs. James Carmalt and Kathleen MacMillan. Un laboratoire équin «The Oral Examination: From Touching Participants will be able to complete an oral examination and and Feeling to Oral Endoscopy and Imaging» sera animé par

230 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY chart the results to appreciate the differences between the light les Drs James Carmalt et Kathleen MacMillan. Les participants N and mirror approach and the oral endoscope. Participants will pourront effectuer un examen maxillo-facial et consigner les also appreciate the benefit of adding routine radiography into a résultats afin d’apprécier les différences entre l’approche à la complete examination of the equine dentition. lumière et au miroir et celle de l’endoscopie maxillo-faciale. Drs. Pierre Amsellem and James Farese are offering 2 sur- Les participants apprécieront aussi le bienfait de l’ajout d’une gical labs. The first lab “Common Surgical Procedures of radiographie de routine dans un examen complet de la dentition the Canine Head and Neck” will allow practitioners to gain équine. confidence in the relevant anatomy and surgical approach to Les Drs Pierre Amsellem et James Farese offrent deux successfully perform unilateral arytenoid lateralization (laryn- laboratoires chirurgicaux. Le premier laboratoire «Common geal “tie-back”), total ear canal ablation and bulla osteotomy Surgical Procedures of the Canine Head and Neck» permettra and sialadenectomy (salivary gland removal). Following a short aux praticiens d’acquérir de la confiance pour l’approche presentation highlighting key procedural details, participants anatomique et chirurgicale pertinente afin de réaliser avec succès will then perform the discussed surgical procedure on canine une latéralisation arythénoïde unilatérale (l’ancrage laryngé sous cadavers. tension), l’ablation totale du conduit auditif, l’ostéotomie de la The 2nd half-day lab, “Mass Resection and Reconstructive bulle et la sialadénectomie (enlèvement de la glande salivaire). Surgery” will help participants become proficient at wide exci- Après une courte présentation soulignant les principaux détails sion techniques for subcutaneous masses, obtaining sufficient de l’intervention, les participants effectueront ensuite l’intervention margin for local control of common malignant tumors. Tension- chirurgicale discutée sur des cadavres de chiens. relieving techniques for wound closure after mass excision will Le deuxième laboratoire d’une demi-journée «Mass Resection be demonstrated and practiced. Common skin flaps for wound and Reconstructive Surgery» aidera les participants à devenir closure will be presented and practiced. compétents pour la réalisation des techniques de larges excisions The CVMA Annual Convention is organized in collaboration des masses sous-cutanées afin d’obtenir une marge suffisante with the Registered Veterinary Technicians and Technologists pour le contrôle local de tumeurs malignes courantes. Les of Canada (RVTTC). Many sessions are appropriate for your techniques de soulagement de la tension pour la fermeture des RVTs and other clinic staff. Of particular interest is the wet lab plaies après l’excision de la masse seront démontrées et mises en “Small Animal Hematology — Examining Reds and Whites” pratique. Les lambeaux de peau communs pour la fermeture de la to be presented by Drs. Cornelia Gilroy and Shelley Burton. plaie seront présentés et pratiqués. The session will begin with a short review of basic blood cell Le congrès annuel de l’ACMV est organisé en collaboration morphology. Then, interesting small animal hematology cases avec Technologues et techniciens vétérinaires agréés du Canada from Canada will be used as mystery cases for participants who (TTVAC). Beaucoup d’ateliers seront appropriés pour vos TVA will each have their own microscope to review blood smears. et d’autres employés de la clinique. Le laboratoire de travaux At timely intervals, cases will be briefly discussed using a pratiques «Small Animal Hematology — Examining Reds and PowerPoint presentation and participants can rate their knowl- Whites», qui sera présenté par les Dres Cornelia Gilroy et Shelley edge with anonymous quizzes using TurningPoint technology Burton, sera particulièrement intéressant. L’atelier débutera par and handheld clickers. Participants will practice the correct un bref tour d’horizon de la morphologie de base des cellules method used for performing saline dilution to help differentiate sanguines. Puis, des cas d’hématologie intéressants des petits between agglutination and rouleaux, as well as practice making animaux provenant du Canada serviront de cas mystères pour blood smears. Additional hematology cases with digital images les participants qui auront leur propre microscope pour évaluer will also be available on laptop computers. les frottis sanguins. À des moments opportuns, des cas seront Thursday, July 13th also features the CVMA Summit entitled brièvement discutés à l’aide d’une présentation PowerPoint et “The Future of Veterinary Medicine: Embracing Change and les participants pourront évaluer leur connaissance lors de tests Innovation.” Guest speakers will discuss upcoming trends that anonymes utilisant la technologie TurningPoint et des cliqueurs Courtesy of the American Association of Equine Practitioners Association Equine of American the Courtesyof Dr./Dr Alex Reiter Dr/Dr James Carmalt Dr./Dre Kathleen MacMillan

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Dr./Dr Pierre Amsellem Dr./Dre Cornelia Gilroy Dr./Dre Shelley Burton

will impact veterinary medicine and daily practice. This year’s portables. Les participants pratiqueront la bonne méthode utilisée CVMA Summit will be chaired by Dr. Troye McPherson, pour la réalisation de la dilution saline afin d’aider à différencier CVMA president-elect. entre l’agglutination et les rouleaux, ainsi que de s’exercer à réaliser In the afternoon, the 2nd National Issues Forum will be des frottis sanguins. Des cas d’hématologie additionnels assortis held focusing on complementary and alternative veterinary d’images numériques seront aussi disponibles sur des ordinateurs medicine. The CVMA Emerging Leaders Program will begin portables. Thursday afternoon and continue on Friday, July 14th. C’est le jeudi 13 juillet que sera présenté le Sommet de l’ACMV Concurrent continuing education sessions run on Friday and qui s’intitulera : «L’avenir de la médecine vétérinaire : Adopter continue until Sunday and will include the following tracks: les changements et l’innovation». Les conférenciers invités companion animal, ruminant, equine, practice management, discuteront les tendances qui auront un impact sur la médecine bovine, animal welfare, and small flock poultry and more. The vétérinaire et la pratique quotidienne. Le Sommet de l’ACMV 2017 topics range from dentistry to soft tissue surgery, from de cette année sera présidé par la Dre Troye McPherson, la diagnostic imaging to ophthalmology, and much more, delivered présidente désignée de l’ACMV. by top-notch speakers. En après-midi, le deuxième Forum sur les enjeux nationaux To reconnect with classmates and friends, don’t miss the PEI portera sur la médecine vétérinaire et parallèle. Par ailleurs, le Kitchen Party on Saturday, July 15 at the Lobster on the Wharf Programme des futurs leaders de l’ACMV débutera le jeudi après- restaurant. With local lobster on the menu paired with local midi et se poursuivra le vendredi 14 juillet. musicians, the evening promises to be memorable! Les ateliers de formation continue parallèles se dérouleront Don’t miss this opportunity to enhance your skills and le vendredi et se poursuivront jusqu’au dimanche et ils incluront knowledge and to reconnect with colleagues. Visit the website les volets suivants : animaux de compagnie, ruminants, équidés, (www.canadianveterinarian.net) to register online. The early bird gestion d’une pratique, bovins, bien-être animal et volaille de registration rate ends on June 1, so be sure to take advantage of petits troupeaux, et plus encore. Les sujets abordés en 2017 the lowest registration rates. Register today! comprendront notamment la dentisterie, la chirurgie des tissus mous, l’imagerie diagnostique, l’ophtalmologie et beaucoup d’autres (by Ruta Klicius, CMP, Manager, Conventions) qui seront présentés par des conférenciers de calibre supérieur. Pour reprendre contact avec vos camarades de classe et vos amis, ne manquez pas le Party de cuisine de l’Île-du-Prince-Édouard qui se déroulera le samedi 15 juillet au restaurant Lobster on the Wharf. Le homard local sera au menu et un groupe de musiciens local se donnera en spectacle afin d’organiser une soirée mémorable! Ne ratez pas cette occasion d’améliorer vos compétences et vos connaissances et de reprendre contact avec vos collègues. Visitez le site Web (www.veterinairesaucanada.net) pour vous inscrire en ligne. Le tarif de l’inscription hâtive prendra fin le 1er juin, assurez-vous donc de profiter des tarifs d’inscription les plus bas et inscrivez-vous dès aujourd’hui! (par Ruta Klicius, CMP, gestionnaire, Congrès)

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The Key to Forward Booking La clé du succès pour la prise de N Appointments rendez-vous à l’avance t is an unfortunate reality that many clients alheureusement, bon nombre de Idon’t book an appointment until their pet Mclients ne prennent pas de rendez-vous is truly ill. In this day and age people are jusqu’à ce que leur animal de compagnie soit busy and they simply forget to schedule that vraiment malade. Aujourd’hui, les gens sont annual exam or wellness visit. Sure, you may très occupés et ils oublient tout simplement send a postcard every year, but who is to say de prendre un rendez-vous pour un examen those don’t end up with all the other junk annuel ou d’effectuer une visite de bien-être. mail…you know, in that drawer, pile, or dare Bien entendu, vous pouvez envoyer une carte I say trash (come on you know you do it too). postale tous les ans, mais elle se retrouvera Perhaps the veterinary profession should probablement dans la pile de circulaires, dans steal a play from the handbook dentists use. un fond de tiroir ou encore, j’oserais même If you’ve visited a dentist any time recently, dire, à la poubelle (avouez que vous le faites you will know how hard it is to leave the aussi parfois). office without scheduling your next cleaning Peut-être que la profession vétérinaire 6 months from now. Their persistence, also pourrait se servir d’une tactique utilisée par called forward booking, should be a corner- les dentistes. Si vous êtes récemment allé chez stone for how veterinary practices handle le dentiste, vous savez qu’il difficile de quitter their patients’ annual exams. le bureau sans prendre le rendez-vous pour le prochain nettoyage You may have been forward booking for years without even dans six mois. Leur persistance, aussi appelée la prise de rendez realizing it. Forward booking simply means booking the pet’s à l’avance, devrait être un pilier de la façon dont les pratiques next visit before it leaves the practice during its current visit. vétérinaires gèrent les examens annuels de leurs patients. Most of the time they are called recheck or progress exams, but Vous prenez probablement des rendez-vous à l’avance depuis why should they only be utilized for that purpose — after all, des années sans même le savoir. La prise de rendez-vous à we all acknowledge the importance of annual exam and well- l’avance signifie simplement que le prochain rendez-vous de ness visits. l’animal sera pris avant qu’il ne quitte la pratique. La plupart du Some may argue that a client will not know what they are temps, on les qualifie d’examen de suivi ou de vérification des doing a year from now and even if they did, how could they ever progrès, mais pourquoi devrait-on seulement les utiliser à cette remember to keep that appointment if they can’t even remember fin — après tout, nous reconnaissons tous l’importance d’un examen to book one. It’s simple — have your front desk staff acknowl- annuel et des visites de bien-être. edge to the client that most of us don’t plan our lives that far in Certaines personnes font valoir qu’un client ne sait pas ce qu’il advance, but since today’s date and time worked then generally fera dans un an et que, même s’il le savait, comment pourrait-il next year’s appointment will too. Have your staff assure them se rappeler de respecter ce rendez-vous s’il ne peut même pas that there will be plenty of reminders leading up to the appoint- se rappeler d’en prendre un? C’est simple — demandez à votre ment and they can always rebook if necessary. While some clients personnel de réception de reconnaître que la plupart d’entre may be resistant to this practice, a majority of clients will actually nous ne planifions pas nos vies si longtemps à l’avance, mais, vu appreciate having the responsibility shifted off of them. que l’heure et la date d’aujourd’hui ont bien fonctionné, alors le The bottom line is that when veterinarians and their practice rendez-vous de l’an prochain fera probablement aussi l’affaire. teams see clients and pets on a regular basis, they receive the Dites à votre personnel de les rassurer qu’il y aura suffisamment de highest quality of healthcare. Forward booking is a simple solu- rappels avant le rendez-vous et qu’ils pourront toujours le reporter tion to afford the opportunity to achieve both goals — healthier au besoin. Même si certains clients peuvent être réticents face à pets and healthier practices. cette pratique, la majorité des clients apprécieront le fait qu’ils ne To learn more on how to implement this program con- portent plus le poids de cette responsabilité. sistently and effectively in your practice, visit the website Ce qui compte vraiment est que lorsque les vétérinaires et les (www.partnersforhealthypets.org/forward_booking.aspx). This équipes de la pratique voient les clients et leurs animaux sur une link will provide you the complete “playbook” on how to deliver base régulière, ces derniers reçoivent des soins de la plus grande this in your practice! qualité. La prise de rendez-vous à l’avance est une solution simple qui offre la possibilité d’atteindre deux buts : des animaux et des pratiques en meilleure santé. Pour en apprendre davantage sur la façon de mettre ce programme en œuvre de manière uniforme et efficace dans votre pratique, visitez le site Web (www.partnersforhealthypets.org/ forward_booking.aspx). Ce lien vous fournira tous les renseignements nécessaires sur la façon dont pouvez préparer votre «plan de match» et mettre cette pratique en œuvre cette méthode dans votre pratique!

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N New Framework Provides Guidance to Canadian Veterinarians on Oversight of Antimicrobial Use Un nouveau cadre de travail fournit des lignes directrices aux médecins vétérinaires canadiens pour la surveillance de l’utilisation des antimicrobiens he Canadian veterinary profession has taken a significant step a profession de médecin vétérinaire au Canada a réalisé des Tforward with the creation of a national framework to address Lprogrès majeurs avec la création d’un cadre de travail national its responsibilities under new federal government regulations dans le but d’assumer ses responsabilités en vertu de la nouvelle for increased veterinary oversight of antimicrobials, which are réglementation du gouvernement fédéral pour une surveillance expected to be implemented by the end of 2017. vétérinaire accrue des antimicrobiens dont la mise en œuvre est The document, “Veterinary Oversight of Antimicrobial Use prévue à la fin de 2017. — A Pan-Canadian Framework for Professional Standards for Le document, «Surveillance vétérinaire de l’utilisation des Veterinarians,” was developed by the Veterinary Pharmaceutical antimicrobiens — Un cadre de travail pancanadien pour les normes Stewardship Advisory Group of the Canadian Veterinary Medical professionnelles régissant les médecins vétérinaires», a été rédigé Association (CVMA) in collaboration with the Canadian par le Groupe consultatif sur la gouvernance des produits Council of Veterinary Registrars (CCVR). pharmaceutiques vétérinaires de l’Association canadienne des The framework provides a template of professional standards médecins vétérinaires (ACMV) en collaboration avec le Conseil that may be used by provincial and territorial veterinary regula- canadien des registraires vétérinaires (CCRV). tory (licensing) bodies when developing their own regulations, Le cadre de travail fournit un modèle pour les normes guidelines, or bylaws relating to veterinarians’ professional professionnelles qui pourra être utilisé par les organismes responsibilities in providing oversight of antimicrobial use. de réglementation provinciaux et territoriaux de la médecine “There was a need for consistency of standards relating to vétérinaire (les Ordres) lors de l’élaboration de leurs propres oversight of antimicrobial use across jurisdictions,” says Dr. Troy réglementations, lignes directrices ou règlements administratifs Bourque, CVMA president. “After much consultation from key en lien avec les responsabilités professionnelles des médecins stakeholders from the veterinary community, producer groups, vétérinaires pour la surveillance de l’utilisation des antimicrobiens. and regulators from across Canada, we are pleased to share this «Il existait un besoin d’uniformité au niveau des normes framework that is intended to contribute to the development concernant la surveillance de l’utilisation des antimicrobiens entre and implementation of uniform regulations across the country.” les divers territoires», dit le Dr Troy Bourque, président de l’ACMV. The framework describes the professional obligations for «Après de vastes consultations auprès des principaux intervenants veterinarians as ‘suggested standards,’ provides a definition of the de la collectivité vétérinaire, des groupes de producteurs et Veterinarian-Client-Patient-Relationship (VCPR), and describes des organismes de réglementation à l’échelle du Canada, nous the professional obligations to be met by veterinarians when sommes heureux de partager ce cadre de travail qui a pour but prescribing a drug. de contribuer à l’élaboration et à la mise en œuvre de règlements In addition, the framework makes several recommendations uniformes partout au pays.» on outstanding issues, including surveillance of antimicrobial Le cadre de travail décrit les obligations professionnelles use and distribution, and continuing education opportunities des vétérinaires sous forme de «normes suggérées», fournit une for veterinary professionals on antimicrobial stewardship. définition de la relation vétérinaire-client-patient (RVCP) et décrit The veterinary profession in Canada will continue to be les obligations professionnelles que doivent respecter les médecins engaged in discussions on the oversight of the use of veterinary vétérinaires lorsqu’ils prescrivent un médicament. antimicrobials at provincial and national levels. De plus, le cadre de travail présente plusieurs recommandations The framework document has been completed and sur des enjeux en suspens, dont la surveillance de l’utilisation et de distributed to all regulatory bodies and CVMA members. It is la distribution des antimicrobiens et les possibilités de formation available for download from the CVMA website (www.canadian continue pour les professionnels vétérinaires dans le domaine de veterinarians.net/documents/pan-canadian-framework). l’antibiogouvernance. La profession vétérinaire canadienne continuera de participer à des discussions sur la surveillance de l’utilisation des antimicrobiens en médecine vétérinaire à l’échelle provinciale et nationale. Le document de cadre de travail a été achevé et distribué à tous les organismes de réglementation et aux membres de l’ACMV. On peut le télécharger sur le site Web de l’ACMV au veterinairesaucanada.net/documents/un-cadre-de-travail- pancanadien.

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N Student Internship with Stage étudiant auprès de Veterinarians Without Borders Vétérinaires sans frontières Canada — Kenya 2016 Canada — Kenya 2016 his past summer, we spent 3 months conducting a service été dernier, nous avons passé trois mois dans le cadre d’un Tproject to help improve dairy cow management, produc- L’ projet visant à améliorer la gestion, la productivité et le tivity and animal welfare for small-holder dairy farmers in bien-être animal des vaches laitières de petits exploitants agricoles Mukurwe-ini, Kenya. This project was based on years of research à Mukurwe-ini, au Kenya. Ce projet s’est fondé sur des années de and work in this region. This student internship and service recherche et de travaux dans cette région. Ce stage étudiant et project was supported by Veterinarians without Borders Canada projet a été appuyé par Vétérinaires sans frontières Canada (VSF), (VWB), a Prince Edward Island-based non-governmental organi- un organisme non gouvernemental établi à l’Île-du-Prince-Édouard zation called Farmers Helping Farmers (FHF), generous personal appelé Farmers Helping Farmers (FHF), des dons personnels donations, and the Sir James Dunn Animal Welfare Centre, généraux et le Sir James Dunn Animal Welfare Centre, dont les coordinated by Dr. John VanLeeuwen, a professor of epidemi- efforts ont été coordonnés par le Dr John VanLeeuwen, professeur ology and ruminant health management, and Chair of VWB. d’épidémiologie et de gestion de la santé des ruminants et président Under the direct training and supervision of PhD candidate de VSF. Dr. Shauna Richards, we trained youth farmer members of the Sous la supervision directe de la candidate au doctorat Wakulima Dairy in Mukurwe-ini. Youth and female farmers Dre Shauna Richards, nous avons formé de jeunes agriculteurs de were our target demographic in order to sustain the Dairy, as the Wakulima Dairy à Mukurwe-ini. Les jeunes fermiers et les femmes current population of member farmers is aging. The Wakulima agricultrices étaient notre public cible en vue de permettre la survie Dairy is an integral source of income for many people in the de l’exploitation laitière, car la population des fermiers membres area. Over 6000 farmers sell milk to the Wakulima Dairy and est actuellement en voie de vieillissement. L’exploitation laitière de FHF has been partnered with them for over 20 years to improve Wakulima Dairy représente une source de revenu pour beaucoup de agricultural production as a foundation for sustainable com- personnes dans la région. Plus de 6000 fermiers vendent du lait à munity development, with the assistance of VWB over the past Wakulima Dairy et FHF fait équipe avec l’exploitation depuis plus de 7 years. 20 ans pour améliorer la production agricole comme fondement du Over the course of our 3-month stay, we visited 40 farms, développement d’une collectivité durable et ce travail s’est fait avec 3 times each. During the first visits, we made alterations to the l’assistance de VSF au cours des sept dernières années. cow stalls to make them more comfortable for the cows. The Pendant notre séjour de trois mois, nous avons réalisé trois alterations allowed the cows to rest more often, and the more visites dans 40 fermes. Pendant les premières visites, nous avons cows rest, the more milk they produce. On the 2nd visits, we apporté des modifications aux stalles des vaches afin d’améliorer trained farmers on how to improve their milking practices and leur confort. Les modifications ont permis aux vaches de se reposer

236 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY cow hygiene in order to prevent mastitis. We also educated plus souvent et plus la vache se repose, plus elle produit du lait. Lors N farmers on how to improve their feeding practices to ensure de la deuxième visite, nous avons formé les fermiers sur la façon that nutrition is optimized for milk production. The education d’améliorer leurs pratiques de traite et l’hygiène de vaches afin de was reviewed and expanded upon during the 3rd and final visit prévenir la mammite. Nous avons aussi enseigné aux fermiers des to each farm, when we held a seminar for neighbor farmers on façons d’améliorer leurs pratiques d’alimentation afin de veiller à ce the host farm. In the future, the hope is that the groups that are que la nutrition soit optimisée pour la production de lait. La formation formed during these seminars will work together to continuously a été révisée et augmentée lors de la troisième et dernière visite improve dairy farming. Through our project we gave seminars to à chaque ferme, lorsque nous avons organisé un atelier pour les over 400 people. Fifty-five percent of the people who attended fermiers voisins de la ferme hôte. À l’avenir, nous espérons que les the seminars were women and 51% were youth. The 40 youth groupes qui sont formés lors de ces ateliers travailleront ensemble farmers saw improvements in their milk production, and most afin de continuellement améliorer la production laitière. Dans le have become very engaged in getting more youth in the area cadre de notre projet, nous avons donné des ateliers à plus de 400 interested in dairy farming. personnes. Cinquante-cinq pour cent des personnes qui ont assisté In addition to educating dairy farmers, we built on last year’s aux ateliers étaient des femmes et 51 % étaient des jeunes. Les 40 pilot project of One Health education in primary schools in the jeunes fermiers ont observé une amélioration de leur production de Mukurwe-ini area. We taught at 7 schools, Grades 6 through 8, lait et la plupart d’entre eux travaillent activement pour intéresser and the topics included how to identify and avoid transmission d’autres jeunes de la région à la production laitière. of diseases (like rabies) between animals and humans, and how En plus d’éduquer les fermiers laitiers, nous avons poursuivi to avoid injury by using proper cow handling. notre projet pilote de l’an dernier pour l’éducation Une santé dans The work we did on farms was truly rewarding. There is a les écoles primaires de la région de Mukurwe-ini. Nous avons sense of satisfaction that comes from giving someone knowledge enseigné dans sept écoles, à des élèves de la sixième à la huitième that will help them to create a sustainable and stable future. année, et les sujets portaient sur l’identification et la prévention de However, as much as we were rewarded through our teaching, la transmission de maladies (comme la rage) entre les animaux et we also found that each and every day contained a learning les humains et comment éviter des blessures en utilisant de bonnes opportunity for us. On a personal level, we found our commu- techniques de manipulation des vaches. nication skills improved. We also learned about the challenges of Le travail que nous avons réalisé dans les fermes était vraiment small-holder dairy farming in Kenya. As is the case in Canada, enrichissant. On tire une grande satisfaction de la communication de dairy farming in Kenya is a full time job. Farmers have to be up connaissances pour aider les personnes à créer un avenir durable at 05:00 for the first milking, spend the morning getting their et stable. Cependant, même si nous tirons de la satisfaction de children to school, complete all the necessary chores on the farm, l’enseignement, nous avons aussi appris quelque chose tous les and gather forage for their cows before the next milking around jours. À un niveau personnel, nous avons constaté une amélioration noon. They also often have another job that they then go to, or de nos aptitudes de communication. Nous nous sommes aussi have to tend to the many other animals or crops on the farm. renseignées sur les défis de la production laitière à petite échelle Working these types of hours can be discouraging when you are au Kenya. Comme c’est le cas au Canada, la production laitière au getting a poor milk return from your cow. However, the Kenyan Kenya est un emploi à temps plein. Les fermiers doivent se lever farmers we have worked with are some of the hardest working à 5 h du matin pour la première traite et ils préparent les enfants people we have ever met. This work ethic, mixed with their pas- pour l’école le matin, effectuent toutes les corvées nécessaires sion for dairy farming and interest in improving, is bound to à la ferme et ramassent le fourrage pour leurs vaches avant la traite suivante à midi. Les fermiers doivent aussi souvent se rendre à un autre emploi ou ils doivent s’occuper d’autres animaux ou récoltes à la ferme. Il peut être décourageant de travailler ces heures lorsque la vache offre un mauvais rendement. Cependant, les fermiers kényans avec lesquels nous avons travaillé figurent parmi les personnes les plus travaillantes que nous avons jamais rencontrées. Cette éthique du travail, qui s’accompagne d’une passion pour la production laitière et d’un intérêt à l’amélioration, se traduira assurément par de nouvelles améliorations dans l’avenir, particulièrement si des programmes comme le nôtre continuent d’être

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N help them see further improvements in the future… especially if offerts pour aider les fermiers à apporter les petits changements programs like ours continue to help educate farmers in the small nécessaires pour augmenter considérablement la production de lait. changes they can make to see large returns in milk production. Nous nous sommes aussi renseignées sur le travail en On a broader scale, we also learned about working in inter- développement international. Notre projet s’appuyait sur le concept national development. Our project was based on the premise of d’Une Santé qui vise à créer un avenir en santé pour les collectivités One Health — creating a healthier future for communities, by en concevant des solutions pour la santé des animaux, des humains creating solutions for animal, human, and environmental health. et de l’environnement. Ce projet nous a vraiment montré comment This project really showed us how making simple changes on a de petits changements peuvent avoir un impact important au small scale can have a big impact on a community. By improving sein d’une collectivité. En améliorant le bien-être des vaches des the welfare of cows on small-holder dairy farms, you can improve petites exploitations laitières, on peut améliorer le revenu mensuel the monthly income for an entire family. When the education de toute une famille. Lorsque cette formation qui a contribué that helped make that change is spread through the community, aux changements est diffusée en sein de la collectivité, on peut you start to see economic stability spread throughout the area. commencer à voir une stabilité économique qui s’installe dans la We have high hopes for the future of this project in the com- région. ing years. The extension team at the Wakulima Dairy has been Nous entretenons de grands espoirs pour l’avenir de ce projet instrumental in helping us reach out to farmers. The hope is that au cours des prochaines années. L’équipe sur le terrain à Wakulima some of the farms we worked on can be used as demonstration Dairy a joué un rôle crucial pour nous aider à communiquer avec les farms where the extension team can continue to hold seminars fermiers. Nous espérons que certaines des fermes où nous avons over the next year, keeping the youth engaged until a new group travaillé pourront servir de fermes de démonstration où l’équipe of interns returns next summer. We know that next year’s stu- sur le terrain pourra continuer à tenir des ateliers au cours de la dents will find this project to be as rewarding as we did; we are prochaine année afin de soutenir l’intérêt des jeunes jusqu’à l’arrivée excited to follow and support their journeys next summer. This des stagiaires l’été prochain. Nous savons que les étudiants de l’été project really emphasizes the importance of engagement from the prochain trouveront aussi ce projet enrichissant et nous avons hâte veterinary community here in Canada and around the world in de suivre et d’appuyer leur parcours. Ce projet insiste réellement sur One Health projects. We feel lucky to have had the opportunity, l’importance de l’engagement au sein de la collectivité vétérinaire ici and look forward to contributing to similar projects throughout au Canada et partout dans le monde dans le cadre de projets Une our veterinary careers. Thank you to everyone who has supported Santé. Nous nous estimons chanceuses d’avoir eu cette occasion et us in this endeavor, it wouldn’t have happened without you! nous avons hâte de contribuer à des projets semblables pendant nos carrières vétérinaires. Merci à toutes les personnes qui ont appuyé (by Katharine White — UCVM student and VWB intern and Julia Nguyen — OVC student and VWB intern) notre projet, nous n’aurions pas pu le faire sans vous! (par Katharine White — étudiante de l’UCVM et stagiaire de VSF et Julia Nguyen — étudiante de l’OVC et stagiaire de VSF)

New Guidelines Ensure Accessible, Des nouvelles directives assurent Transparent Animal Research des résultats en recherche animale Results qui sont accessibles et transparents ew guidelines for authors reporting observational studies e nouvelles directives à l’intention des auteurs pour la Nin animals were published in December 2016. The guide- Dprésentation de rapports sur les études d’observation des lines are the work of an international group of 16 experts, with animaux ont été publiées en décembre 2016. Les directives Dr. Jan Sargeant, Ontario Veterinary College, and Dr. Annette découlent des travaux d’un groupe international composé de O’Connor, Iowa State University College of Veterinary 16 experts, dont la Dre Jan Sargeant, de l’Ontario Veterinary Medicine, as co-chairs. The objective of the guidelines is to College, et la Dre Annette O’Connor, du Collège de médecine help authors to produce clear and well organized reports of their vétérinaire de l’Université de l’État de l’Iowa, étaient coprésidentes. research and to ensure that readers are informed about all the L’objectif de ces directives consistait à aider les auteurs à produire critical elements that go into the design, analysis, and interpreta- des rapports clairs et bien organisés sur leur recherche et à veiller tion of the study. The writers have produced useful documents à ce que les lecteurs soient informés à propos de tous les éléments referred to as STrengthening the Reporting of OBservational critiques qui entrent dans la conception, l’analyse et l’interprétation studies in Epidemiology (STROBE) statements and checklist. de l’étude. Les rédacteurs ont produit des documents utiles These can be accessed on the website (www.strobevet-statement. comportant des énoncés et des listes de contrôle qui s’intitulent org). The 22-item checklist should be of enormous value to «STrengthening the Reporting of OBservational studies in researchers, readers, reviewers, and editors. Epidemiology (STROBE)». On peut consulter ces documents sur le site Web (www.strobevet-statement.org). La liste de contrôle de 22 articles devrait être d’une immense valeur pour les chercheurs, les lecteurs, les évaluateurs et les rédacteurs.

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Order Supplies through Staples Commandez des fournitures par N Business AdvantageTM and Save l’entremise de Staples Avantage Money! AffairesMC et économisez taples Business AdvantageTM is the business division of taples Avantage AffairesMC est la division commerciale de SStaples, Canada’s largest supplier of office products. The SStaples, le plus important fournisseur de produits de bureau CVMA negotiated a group purchasing agreement to provide du Canada. L’ACMV a négocié une entente d’achat de groupe afin CVMA members with discounted office supplies. d’offrir des réductions sur le prix des fournitures de bureau aux Staples Business AdvantageTM saves money for CVMA mem- membres de l’ACMV. bers who own a practice or small business, are opening a practice Staples Avantage AffairesMC permet de réaliser des économies or are building or renovating a home office. The competitive pour les membres de l’ACMV qui sont propriétaires d’une pratique ou prices are usually only available to businesses with 401 employ- d’une petite entreprise, qui ouvrent une pratique ou qui construisent ees but the CVMA group purchasing agreement allows CVMA ou rénovent un bureau à domicile. Les prix concurrentiels sont members to benefit from these prices, regardless of their business habituellement seulement offerts aux entreprises comptant plus de size. Also included in CVMA’s partnership with Staples Business 40 employés, mais l’entente d’achat de groupe de l’ACMV permet AdvantageTM are 3 categorized lists (cleaning products; toner aux membres de l’ACMV de profiter de ces prix réduits, peu importe and ink cartridges; general items) of specially priced items, lower la taille de leur entreprise. Le partenariat de l’ACMV avec Staples than the catalogue, exclusive to CVMA members. Avantage AffairesMC comprend trois catégories de produits (produits Staples Business AdvantageTM makes buying office products de nettoyage; cartouches d’encre; articles généraux) qui sont offerts easy by providing: à des prix spéciaux inférieurs aux prix du catalogue exclusivement • Competitive pricing with the Staples Business Advantage Net aux membres de l’ACMV. Catalogue Staples Avantage AffairesMC facilite l’achat de produits de bureau • Free next-business-day delivery across Canada on orders en offrant : over $50 • Des prix concurrentiels grâce au Catalogue en ligne de Staples • Easy to use online ordering Avantage • Excellent customer care with dedicated local account • La livraison le lendemain gratuite partout au Canada pour les managers commandes de plus de 50 $ • Easy to browse catalogues. • Une commande en ligne d’utilisation conviviale To open a Staples Business AdvantageTM customer • Un excellent service à la clientèle avec des chargés de comptes account under the CVMA group agreement, you’ll need to attitrés request an account application from the CVMA by e-mail • Des catalogues faciles à consulter. MC ([email protected]) or call 1-800-567-2862. The 3 cat- Pour ouvrir un compte client Staples Avantage Affaires en vertu de l’entente de groupe de l’ACMV, vous devrez demander un egorized lists of specially priced items are on the CVMA website formulaire d’ouverture de compte auprès de l’ACMV par courriel (www.canadianveterinarians.net), under Value of Membership — ([email protected]) ou appeler au 1-800-567-2862. Les trois Member Benefits & Services. listes catégorisées d’articles offerts à prix spéciaux se trouvent sur le site Web de l’ACMV (www.veterinairesaucanada.net), sous Valeur de l’adhésion — Avantages et services aux membres.

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N Dr. Grant Maxie — 2016 Carl Block Dr Grant Maxie — lauréat du prix Award recipient Carl-Block de 2016 ach year the Canadian Animal Health Coalition (CAHC) haque année, la Coalition canadienne pour la santé des Epresents the Carl Block Award to an individual nominated Canimaux (CCSA) décerne le prix Carl-Block à une personne by his or her peers for outstanding contributions to the field of mise en nomination par ses pairs pour sa contribution exceptionnelle livestock animal health. This award is in memory of Carl Block, au domaine de la santé des animaux d’élevage. Ce prix est à la who was chair of the CAHC when he passed away as the result mémoire de Carl Block, qui était président de la CCSA lorsqu’il est of a small plane crash in May 2002. décédé dans l’écrasement d’un petit avion en mai 2002. The Canadian Animal Health Coalition (CAHC) is honored La Coalition canadienne pour la santé des animaux (CCSA) a to have named Dr. Grant Maxie of Puslinch, Ontario as this eu l’honneur de décerner au Dr Grant Maxie de Puslinch (Ontario) year’s recipient of the Carl Block Award. Through his hard work le prix Carl-Block de cette année. Par son excellent travail et son and dedication, Dr. Maxie has made many significant contribu- dévouement, le Dr Maxie apporte une précieuse contribution au tions to the Canadian animal health industry. secteur canadien de la santé animale. Dr. Maxie has been integrally involved in the laboratory Le Dr Maxie a une carrière remarquable et fait partie intégrante management and surveillance scene both in Canada and inter- du domaine de la surveillance et de la gestion de laboratoire au nationally over his distinguished career. Since 1997 he has been Canada et à l’étranger. Directeur du Laboratoire de santé animale director of the Animal Health Laboratory (AHL), University (LSA) de l’Université de Guelph depuis 1997, il est aussi depuis of Guelph and since 2007 co-executive director of Laboratory 2007 codirecteur administratif des Services de laboratoire de Services, University of Guelph. In these positions he has pro- cette université. Dans ces fonctions, il a piloté plusieurs initiatives vided leadership in several national diagnostic and surveillance nationales de diagnostic et de surveillance. En tant que directeur initiatives. Most recently, he has led the Animal Health Lab du LSA, il a fourni des directives au secteur durant les éclosions and provided guidance to industry through the recent Porcine récentes de diarrhée épidémique porcine virale et de grippe aviaire Epidemic Diarrhea Virus (PEDV) and Avian Influenza outbreaks en Ontario. Il est chef du Programme de surveillance des maladies in Ontario. He is the project chair for the Disease Surveillance 2013–2018 du MAAARO, un programme administré par le LSA qui Plan 2013–2018, an Ontario Ministry of Agriculture, Food and améliore l’exercice de la surveillance des maladies en Ontario et qui Rural Affairs (OMAFRA) project, administered by AHL that has y contribue également à l’échelle nationale. enhanced the conduct of disease surveillance in Ontario and has Le dossier de candidature du Dr Maxie pour le prix Carl-Block contributed nationally as well. s’accompagnait de plusieurs lettres d’appui d’organismes canadiens Accompanying Dr. Maxie’s nomination for the Carl Block et étrangers, ce qui témoigne de son influence à l’échelle mondiale. Award were several letters of support from both Canadian and Nous sommes aussi fiers de signaler que le Dr Maxie est un ancien international bodies, which is a testament to his influence globally . rédacteur en chef de La RVC. We are also proud to point out that Dr. Maxie is a former editor- Étant donné que les principaux critères de remise du prix in-chief of The CVJ. Carl-Block sont que le lauréat ou la lauréate fasse preuve de Considering that the primary criteria to receive the Carl leadership, d’engagement et d’un intérêt inconditionnel pour Block Award is that recipients demonstrate leadership, commit- l’amélioration du secteur de l’élevage au Canada, on voit aisément ment and passion for enhancing animal agriculture in Canada, pourquoi le Dr Grant Maxie en est le lauréat en 2016. it is easily apparent why Dr. Grant Maxie is the 2016 recipient.

Dr./Dr Grant Maxie

240 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY Article

Semitendinosus myopathy and treatment with adipose-derived stem cells in working German shepherd police dogs

Melissa A. Gibson, S. Gary Brown, Nancy O. Brown

Abstract — Semitendinosus myopathy has been treated with numerous surgical and non-surgical therapies resulting in recurrence of lameness within 2 to 9 months. Eleven cases of semitendinosus myopathy diagnosed in 8 working police dogs that were treated with adipose-derived mesenchymal stem cells were retrospectively evaluated. At short-term follow-up , 6 mo, ultrasound and gait evaluations revealed a mean reduction in the overall intramuscular lesion size of 54.82% (SD 1/2 18.02; range: 30.5% to 82.7%) and reduction in the Visual Assessment Score (VAS) of 1 to 3 points. At long-term follow-up . 1 y, in 8 cases the dogs had a normal gait and in 3 cases the dogs had an improved gait compared with initial examination, and all 8 dogs returned to active police work. Fisher’s exact test resulted in P = 0.000008 when comparing published historical reports and these 11 cases for resolution of lameness and return to active duty.

Résumé — Myopathie du muscle semi-tendineux et traitement à l’aide de cellules souches adipeuses chez des chiens policiers Bergers allemands. La myopathie du muscle semi-tendineux a été traitée à l’aide de nombreuses thérapies chirurgicales et non chirurgicales qui ont produit une récurrence de la boiterie dans un délai de 2 à 9 mois. Onze cas de myopathie du muscle semi-tendineux diagnostiqués chez 8 chiens policiers qui avaient été traités à l’aide de cellules souches mésenchymateuses adipeuses ont été évalués rétrospectivement. Au suivi à court terme de , 6 mois, les évaluations de l’échographie et de la démarche ont révélé une réduction moyenne de la taille de la lésion intramusculaire totale de 54,82 % (SD 1/2 18,02; écart : de 30,5 % à 82,7 %) et une réduction de la note d’évaluation visuelle (NÉV) de 1 à 3 points. Au suivi à long terme de . 1 an, 8 cas avaient une démarche normale et 3 avaient une démarche améliorée comparativement à l’examen initial et les 8 chiens sont retournés au travail policier actif. La méthode exacte de Fisher s’est traduite par un résultat de P = 0,000008 lors de la comparaison avec des rapports historiques publiés et ces 11 cas de résolution de boiterie et de retour au service actif. (Traduit par Isabelle Vallières) Can Vet J 2017;58:241–246

Introduction tion work, racing, or elite agility competition. This injury can be career ending for working dogs due to the secondary emitendinosus myopathy is an uncommon disease in fibrosis and muscle contracture that occur following this type companion animals, documented in the German shep- S of injury (1–6). herd, Belgian shepherd, Doberman pinscher, St. Bernard, and The semitendinosus muscle “originates from the ischiatic old English sheepdog breeds (1–4). The exact etiology of semi- tuberosity, passes deep to the gracilis muscle, and inserts on tendinosus myopathy is unknown. A higher incidence occurs the medial aspect of the tibia distal to the insertions of the in working dogs which exert an excessive amount of acute force semimembranosus and gracilis muscles. This muscle functions on the hamstring muscle group, such as dogs used for protec- to extend the hip, stifle, and tarsus and flex the stifle when in a non-weight-bearing position” (2). After this muscle is trauma- Pennsylvania Veterinary Specialty and Emergency Associates at tized, lameness ensues that can be acute in onset, or progress Hickory Veterinary Hospital, 2303 Hickory Road, Plymouth over a period of weeks to months before reaching a plateau (2,5). Meeting, Pennsylvania 19403, USA (Gibson, N.O. Brown); The exact cause of the injury is not always identifiable. However, Veterinary Orthopedic Surgery Service, 1618 Washington Blvd, the secondary fibrosis that ensues results in a characteristic gait Fremont, California 94539, USA (S.G. Brown) abnormality, in which “all affected dogs have a shortened stride Address all correspondence to Dr. Melissa Gibson; e-mail: with a rapid, elastic medial rotation of the paw, external rotation [email protected] of the hock, and internal rotation of the stifle during the swing Use of this article is limited to a single copy for personal study. phase of the stride” (4). The fibrosis is generally palpable as a Anyone interested in obtaining reprints should contact the firm, taught band that extends from the ischiatic origin of the CVMA office ([email protected]) for additional semitendinosus muscle to its insertion along the medial aspect copies or permission to use this material elsewhere. of the tibia (1–5).

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Table 1. Ultrasonographic measurementsa of intramuscular tears at diagnosis and short-term follow-up Initial Muscle tear % Reduction Leg muscle tear Initial size (mm) Scar tissue in muscle Patient affected size (mm) scar tissue , 6 months PO , 6 months PO tear size Cris Left 30.8 3 8.1 None 15 3 11 None 33.8 Hunther Left 41 3 18 Unknown 30 3 7 18 3 3 71.5 Jagob Right 9 wide Unknown 5.4 wide Unknown 40.0 Jagob Left 7 wide Unknown 4.1 wide Unknown 41.4 Brixb Left 40 3 10 10 3 2 15 long None 62.5 Brix Right 24 3 6 Chronic 20 3 5 None 30.5 Sandrob Left 2 wide None 1 wide None 50.0 ARTICLE Marco Right 40 3 5 None 36 3 2.5 Unknown 55.0 Tom Right 100 3 12 None 80 3 2.6 None 82.7 Arnyb Left 52 long Unknown 10 long Unknown 80.8

a A single case was excluded from this analysis due to missing ultrasonographic information from the medical record. b The semitendinosus muscle tears were only measured in width ultrasonographically for these cases; the percent reduction was calculated by dividing the follow-up width measurement by the initial width measurement. PO — post-implantation of MSC.

Table 2. Visual Assessment Scoresa at presentation, short-term, record for this case, and these findings were included in the and long-term follow-up overall analysis. Leg VAS at VAS VAS Within approximately 1 wk of initial examination, all dogs , . Patient affected presentation 6 months PO 1 year PO underwent an initial ultrasound examination of the affected Cris Left 3 2 1 limb by the same board-certified ultrasonographer, David Hunther Left 4 2 1 Dettweiler DVM, DACVR. Any lesions identified were mea- Jago Right 4 2 3 Jago Left 1 1 1 sured in length and/or width and given a visual description Brix Left 2 2 2 in regard to disruption of fiber pattern and evidence of scar Brix Right 4 1 2 tissue formation (Table 1). Dogs were also graded on a Visual Sandro Left 3 2 Lost to follow-up Assessment Score (VAS) (1 — normal, 2 — mildly affected, Marco Right 2 1 1 3 — moderately affected, 4 — severely affected, and 5 — Tom Right 2 1 1 extremely affected) by a single examiner, S. Gary Brown DVM, Arny Left 3 2 1 Jim Right 2 1 1 DACVS (Table 2). Within 1 wk of the initial ultrasound, adipose tissue was har- a Score definitions: 1 — normal; 2 — mildly affected; 3 — moderately affected; 4 — severely affected; 5 — extremely affected; PO — post-implantation of MSC. vested for treatment with MSC. Dogs were premedicated with a combination of an opioid [Buprenorphine; Par Pharmaceuticals, Historically, semitendinosus myopathy and secondary fibrosis Spring Valley, New Jersey, USA, 0.01 to 0.02 mg/kg body weight have been treated by various methods including rest, antioxi- (BW), IM; Butorphanol (Merck, Spring Valley), 0.08 mg/kg dants, non-steroidal anti-inflammatory drugs, steroids, physical BW, IM; morphine (West-Ward, Eatontown, New Jersey, USA), therapy and a variety of surgical procedures (myotenectomy, 0.4 to 0.5 mg/kg BW, SC]; benzodiazepine (Diazepam; Hospira, myectomy). These therapies were unsuccessful at preventing the Lake Forrest, Illinois, USA), 0.3 to 0.5 mg/kg BW, IV; and formation of fibrous tissue, and all affected dogs were unable to phenothiazine (Acepromazine; Henry Schein, Dublin, Ohio, return to their full activity (1–4). Based on a published report USA), 0.02 to 0.06 mg/kg BW, IM. The dogs were then induced of 2 cases (7), we hypothesized that by treating semitendinosus with intravenous Propofol (Zoetis, Kalamazoo, Michigan, USA), muscle tears with adipose-derived mesenchymal stem cells 0.3 to 2.6 mg/kg BW to effect, and maintained on Isoflurane (MSC), the degree of scar tissue formation within the muscle gas anesthesia. Each dog received IV Lactated Ringers Solution would be reduced, and the affected dogs would be able to return (10 mL/kg BW per hour), and was monitored for non-invasive

to normal activity. blood pressure (NIBP), oxygen saturation (SPO2), end tidal cardon dioxide (EtCO2), temperature and electrocardiogram Materials and methods (ECG) during the anesthetic procedure. Cases of pelvic limb lameness that were presented between Approximately 230 g of falciform fat were aseptically July 2008 and May 2012 to the Veterinary Orthopedic Surgery obtained through a ventral midline laparotomy and placed Service in Fremont, California, USA were retrospectively evalu- in sterile transport centrifugation vials with 5 mL of a sterile ated. A total of 11 cases diagnosed with semitendinosus myopa- buffered saline solution (8). The ventral midline incision was thy in 9 dogs were available for evaluation. Of the 9 dogs, 1 had closed in a routine 3-layer fashion with absorbable suture concurrent bilateral semitendinosus muscle tears at the time of (2-0 or 0 monofilament PDS; Ethicon, Cincinnati, Ohio, USA). diagnosis, and another dog had semitendinosus muscle tears The adipose tissue was shipped overnight to the Vet Stem pro- in each pelvic limb, approximately 10 mo apart. A single case cessing facility, and returned within 48 h from the collection of semitendinosus myopathy was missing the ultrasonographic date for implantation (8). report in the medical record, and was excluded from ultrasono- At the time of implantation, dogs were sedated with either graphic analysis. Gait evaluation was reported in the medical an opioid alone (Butorphanol 0.1 to 0.2 mg/kg BW, IM) or a

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A B ARTICLE

Figure 1. Ultrasonographic images of normal (left) and abnormal (right) semitendinosus muscles. A — Normal parallel muscle fiber pattern outlined in the white oval. B — Hypoechoic lesion and disruption of the normal fiber pattern indicative of a muscle tear outlined in the white oval.

A B

Figure 2. Ultrasonographic images of the semitendinosus muscle pre- and post-treatment. A — At initial diagnosis there is disruption of the normal parallel fiber pattern with a large hypoechoic intramuscular lesion (outlined in the white oval), indicative of a grade 3 muscle injury (9). B — One month post-MSCs injection, there is a more parallel fiber pattern with a small hypoechoic intramuscular lesion (outlined in the white oval), indicative of a grade 2 muscle injury (9).

combination of an opioid (Butorphanol 0.08 mg/kg BW, IM), regard to disruption of fiber pattern and evidence of scar tissue a phenothiazine derivative (Acepromazine 0.04 to 0.18 mg/kg formation. The same VAS grades were used to re-assess for any BW, IM) and a benzodiazepine (Diazepam 0.3 to 0.4 mg/kg improvement or worsening of gait. BW, IV). In 4 of the 11 cases the dogs were induced with Propofol (0.3 to 2 mg/kg BW, IV), maintained on Isoflurane gas Results anesthesia and given IV Lactated Ringers Solution (10 mL/kg All 11 cases were presented with a history of an acute to chronic BW per hour) during the procedure. The lesions within the onset of pelvic limb lameness. The lameness appeared in all dogs semitendinosus muscles were identified, and 1 to 3 aliquots after lunging activities during Schutzhund training occurring (0.6 mL pre-filled syringes) of adipose-derived MSC were several hours to 3 mo before presentation. At initial evaluation, injected intralesionally under ultrasound guidance. A second all 11 cases were diagnosed with a semitendinosus myopathy. injection (5 to 6 mL pre-filled syringe) was administered intrave- Each of the 11 cases of semitendinosus myopathy had a short nously over 2 min through a previously placed IV catheter. The stride in the affected limb, circumduction of the affected limb dogs were discharged to their handlers the day of implantation during ambulation, and a palpably enlarged and painful semi- with instructions for rest and no additional Schutzhund training tendinosus muscle. On VAS assessment of the 11 cases, 3 were for the following 12 wk. severely affected, 3 were moderately affected, 4 were mildly Each case had short-term follow-up (, 6 mo) and long-term affected, and 1 had a normal gait in the affected limb. In this follow-up (. 1 y) for gait evaluation by the examiner who con- case, the semitendinosus muscle tear was found incidentally on ducted the initial examination (Table 2). A follow-up ultrasound initial ultrasound examination when the patient was presented examination was also performed at the short-term follow-up for contralateral pelvic limb lameness (Table 2). (Table 1). On ultrasonography, each lesion was identified, mea- In 8 of 10 cases, initial ultrasonographic findings of the sured in length and/or width and given a visual description in semitendinosus muscle included hypervascularization of swollen

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Table 3. Fisher’s exact test comparing normal gait versus inflammatory medications) or surgical procedures (complete abnormal gait at long-term follow-up myotenectomy, segmental myectomy or myotenectomy, full Normal gait Lameness thickness myectomy or myotenectomy, tenorrhaphy, tenotomy, . 1 year . 1 year Row totals myotenotomy) (1–4). Medical management has been unreward- MSC treated cases 7 3 10 ing with limited improvement in overall function of the limb in Historical published cases 0 29 29 the short and long term periods. Surgical therapy has resulted Column totals 7 32 39 (Grand total) in resolution of the abnormal gait in the initial post-operative Fisher’s exact test statistic value is 0.000008. period, but all cases had documented recurrence of lameness within 2 to 9 mo after surgery (1–4).

ARTICLE areas near the origin of the semitendinosus muscle, hypoechoic A novel therapy for musculoskeletal injuries involves intral- fluid pockets, and disruption of the normal fiber pattern, indica- esional or intravenous injections with mesenchymal stem cells. tive of an intramuscular tear (Figure 1). In 3 of 10 cases, there These stem cells have a high proliferative potential, ability to was evidence of an irregular-appearing fiber pattern (no longer generate primary colony-forming unit fibroblasts (CFU-F) parallel in orientation), indicative of early scar tissue formation. and the ability to differentiate into bone, fat, cartilage, skeletal Using a human ultrasonographic grading scheme (9), 8 of muscle, tendon, and nerve tissues (10–15). They can be derived 10 cases were classified as a grade 3 muscle injury at the ini- from a variety of tissues, including bone marrow, adipose tissue, tial ultrasound examination, where there is “discontinuity of muscle, tendon, dental pulp, periodontal ligament, umbilical the muscle…and intermuscular, perifascial and subcutaneous cord blood, placenta, periosteum, liver, cartilage, synovium, fluid collections are common.” The remaining 2 cases were synovial fluid, spleen, and thymus (10,16,17). Each of these tis- classified as a grade 2 muscle injury, where there is “. 5% but sues has limitations in regard to invasiveness for harvesting, time , 100% disruption of the cross-sectional area of the muscle… necessary for processing and culturing of stem cells, and overall an intramuscular fluid collection may be seen surrounded by a yield. Kisiel et al (11) found periosteum to be a superior tissue hyperechoic halo.” source in providing the greatest number of MSCs per gram of At the short-term follow-up examination , 6 mo after tissue, followed by adipose tissue, muscle, and bone marrow. inoculation with MSC, the VAS had remained static at a score Adipose tissue is an excellent source of MSC that can be of 2 or less in 2 of the 11cases. It had improved in 9 of the harvested from various sites, including subcutaneous sites, 11 cases, with a reduction in the VAS score by 1 to 3 points falciform tissue, and omental tissue (8). Techniques for har- (Table 2). There was a mean reduction in the overall intramus- vesting adipose tissue include liposuction under sedation (11), cular lesion size of 54.82% (SD 1/2 18.02; range: 30.5% to incisional techniques with local anesthetics (12), and intra- 82.7%) (Figure 2). In 2 of 10 cases, scar tissue formation that abdominal techniques under general anesthesia (8). Due to the was detected at the initial evaluation had completely resolved. ease of obtaining falciform fat under a short general anesthetic In 1 of 10 cases, no scar tissue formation was documented at procedure, we elected to use this as the source of adipose MSC the initial evaluation, but the subsequent evaluation revealed in this study. As the dogs were all working German shepherd suspected scar tissue formation. The human ultrasonographic police dogs, they required sedation or general anesthesia for grading scheme of muscle tears (9) revealed a static grade in ultrasound diagnosis, which allowed acquisition of the falciform 6 of 10 cases, or a single grade of improvement from grade 3 to adipose tissue under the same anesthetic procedure. grade 2 in 4 of 10 cases. Several reports in canine, murine, equine, and non-human At the long-term follow-up examination . 1 y post- primate models have shown that MSC obtained from adipose implantation of MSC compared with initial presentation, the tissue, muscle, or bone marrow have the ability to migrate to VAS was normal in 7 of 10 cases. One case was lost to long- regions of inflammation/trauma, help restore normal architec- term follow-up. Two cases had improved VAS by 1 to 2 grades. ture, and improve function in skeletal muscle and tendon tissues A single case remained static in the VAS at the grade of 2. (13–15,17–23). Many of these reports evaluated functional Ultrasonographic information was not obtained at the long-term outcomes, histological and/or immunological samples, or ultra- follow-up examination. sound examination to help determine the effectiveness of MSC Fisher’s exact test was used to evaluate the 11 cases herein therapy. Musculoskeletal ultrasound is a non-invasive method compared with the 31 published historical cases for resolution that is extensively used within the equine industry for evaluating of lameness and return to active duty (Table 3). One case in muscular architecture for diagnosis of muscular contusions/tears this study was lost to long-term follow-up; 2 of the published and for evaluating changes after therapy (12,15,22,23). historical cases were lost to long-term follow-up. All 3 of With adipose-derived MSC therapy, the 11 cases in this these cases were excluded from analysis when conducting the study showed improvement in gait analysis (VAS scores) in the Fisher’s exact test. There was a statistically significant difference short- and/or long-term follow-up period compared with initial (P = 0.000008) between the MSC-treated cases and the 29 his- evaluation. Within 3 mo of diagnosis and adipose-derived MSC torical cases that were not treated with MSC. intralesional injections, all of the affected dogs had returned to full training level and competition or work. At long-term follow- Discussion up, 1 y or more after treatment, the dogs in all 10 cases were Previous therapies for semitendinosus myopathy have included still on active duty with improved (7 of 10) or static (2 of 10) medical management (rest and a combination of anti- gaits on visual assessment scores. A single case did not have a

244 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY

recurrence of lameness within 2 to 9 months in all cases (1–4). This demonstrates that adipose-derived MSCs may be a novel and beneficial treatment option for dogs with semitendinosus myopathy. There are a number of limitations to this study, including being a retrospective analysis of current semitendinosus

myopathy cases compared to previously published reports. Since ARTICLE these dogs were all police force dogs on active duty at the time of diagnosis, histological and immunohistochemical analysis were not performed to further evaluate muscle architecture. Postmortem histopathologic samples could not be obtained; those dogs that expired were cremated elsewhere. Long-term follow-up ultrasonographic examinations were not performed in this study. This may account for the difference between the 60% static ultrasonographic grade at short-term follow-up compared to the 70% normal VAS score at long-term follow-up. In addition, with semitendinosus myopathy being an uncommon disease limited mainly to working or highly athletic dogs, there is a small number of cases presented here for evaluation. Despite these limitations, there are several important features of this study. A single examiner was used to diagnose, make all visual assessment scores, and obtain the falciform adipose tissue for all cases. The same board-certified radiologist was used for initial and post-treatment evaluation of the semitendinosus muscle, as well as ultrasound-guided injections in all 11 cases of semitendinosus myopathy. Controlling these 2 major aspects helped to eliminate intra-observer variability in diagnosis, initial evaluation, treatment, and post-therapeutic evaluation. The same processing facility was used for all 11 cases, which helped to control environmental, procedural, or packaging variables that may have altered the MSC viability. Future studies evaluating semitendinosus myopathy would be strengthened by using histopathological evaluation of the muscle at initial diagnosis and post-MSC therapy. Histopathological evidence would be able to document disruption of the myofiber orientation and/or presence of scar tissue formation after the Figure 3. Post-MSC treated German shepherd dog, Brix, during injury. It would also allow documentation of whether the nor- active Schutzhund training. mal parallel orientation of the myofibers is repaired post-MSC therapy or is replaced by scar tissue formation. Obtaining a biopsy sample pre- and post-MSC therapy may long-term follow-up examination, but the dog was on active be difficult to achieve in a controlled manner. Naturally occur- duty as reported by the police department canine force. ring semitendinosus myopathy is uncommon, and it is difficult The ultrasonographic grade applied to each of the 10 cases to replicate this pathology or create a model for evaluation. (9) revealed a static grade in 6 of 10 and a single grade improve- Several equine studies have used collagenase to create artificial ment in 4 of 10 at the short-term follow-up examination. To the lesions in tendinous structures as a model to determine the best of the authors’ knowledge, there is no comparable grading value of MSCs (12,15,22,23), but this has not been evaluated scheme that has been validated in the veterinary literature. in equine muscle tissue to the best of the authors’ knowledge. At the time of writing (2015), 5 of the 9 dogs had been In conclusion, this study demonstrated that semitendinosus euthanized in previous years for causes unrelated to injury or myopathy treated with adipose-derived MSCs can improve, MSC therapy (hepatic neoplasia, chronic renal failure, inter- or help prevent progression, of the career-ending fibrosis and vertebral disc herniation, unknown neoplasia, unknown cause). muscle contracture that occurs with this pathology. Initial These deaths occurred between 2 to 5 y after adipose-derived diagnosis of semitendinosus myopathy is easily confirmed by MSC treatment. The remaining 4 dogs were alive and doing ultrasound examination, and falciform adipose tissue can be well (Figure 3). One dog was still on active duty with the police collected under a short anesthetic procedure at the time of initial force, and the other 3 were retired. There was no documented ultrasound examination. All 9 affected dogs returned to active recurrence of lameness in the affected pelvic limb in any of the police duty with no restrictions and continued on active duty 11 cases in this study, unlike historical controls that showed until their retirement or demise from unrelated diseases 2 to

CVJ / VOL 58 / MARCH 2017 245 ARTICLE 10. Executive Officer of Vet-Stem. DACVR andRobert J.Harman, DVM, MPVM,Founder, Chief We acknowledge contributionsby David Dettweiler, DVM, within 2 to 9 mo in all cases. the reported historical controls, in which there was recurrence 5 y after MSC implantation. This is a vast improvement from 11. 9. 6. 5. 4. 3. 2. aughn LC. Muscle and tendon injuries in dogs. J Small Anim Pract 1. 8. 7.

career and a balanced life. abalanced and career helps veterinarians achieve asuccessful Association Medical Canadian VeterinaryThe

1173–1185. intheeliteathlete.BrImaging JRadiol2012;85: ofmuscleinjury L January 3, 2017. V B S Meeting Speakers Notes, July 2012. Canapp SO,Jr myopathy in 18 dogs. J Am Anim Hosp Assoc 1997;33:177–188. Le dog. Aust Vet J 1989;66:259–261. C of thesemitendinosusmuscleinfourdogs. Vet Surg 1981;10:169–174. M 1979;20:711–736. V A Stem Cell Discovery 2012;2:41–44. for severe muscletearsinworking German shepherds: Two casereports. Clin North Am Small Anim Pract 2002;32:267–284. K J Cell Physiology 2009;218:237–245. multipotential mesenchymmal/stromal stemcellsinskeletaltissuerepair. BP, Nino-Fong R.Isolation, characterization,andinvitro proliferation teiss JE. Muscle disorders and rehabilitation in canine athletes. Vet et-Stem c2011.Available from: http://www.vet-stem.com/ Lastaccessed rown SG, Harman RJ, Black LL. Adipose-derived stem cell therapy ee JC, Mitchell AWM, Healy JC. Olympic special feature: rthur A, Zannettinorthur A, Gronthos S. The therapeutic applications of isiel AH, McDuffee Masaoud LA, E, Bailey TR, Esparza Gonzalez larke RE. Fibrosis and contracture of the semitendinosusa musclein oore RW, Rouse GP, Piermattei DL,Ferguson HR.Fibrotic myopathy wis DD,Shelton GD,Piras A,et . Sports related softtissueinjuries. AVORE Summer Acknowledgments References Visit Visit canadianveterinarians.net/practice-economics/business-management

al. Gracilis orsemitendinosus FOR PERSONAL

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12. 13. 14. 16. 15. 17. 18. 20. 19. 21. 22. 23. USE

K tissue, muscle and periosteum. Am J Vet Res 2012;74:1305–1317. of canine mesenchymal stem cells derived from bone marrow adipose V 39:678–683. tendonandskeletalmusclerepair.cells forbone,cartilage, Bone2006; N adipose-derived stem cells. Cell Transplant 2010;19:279–289. Isolation, characterizationanddifferentiation potentialofcanine S primate skeletalmuscle.JNeuropathol Exp Neurol 2011;70:770–778. several millimiterstofusewithdamagedmyofibers innonhuman with collagenase-induced tendinitis. Am J Vet Res 2008;69:928–937. adipose-derived nucleatedcellfractionsontendonrepair inhorses O 2011;39:1912–1922. viacontusion enhancement injury of angiogenesis. Am J Sports Med muscle-derived stemcellsacceleratesskeletalmusclehealingafter 2012;94:609–617. stem-cell treatment of skeletal muscle injury. J Bone Joint Surg Am P B 574–579. ameliorate muscle function in dystrophic dogs. Nature 2006;444: S Regen Med 2008;2:169–183. P Med Med Res 2011;1:486–500. The evolving role ofbonemarrow-derived mesenchymalstemcells.Br G superficial digital flexor tendon. Equine Vet J 2012;44:25–32. onstrates improved outcomeinhorseswithoverstrain ofthe injury Implantation of bone marrow-derived mesenchymal stem cells dem- A clinical report. Res Vet Sci 2013;95:272–277. stromal cellsforregeneration ofinured equineligamentsandtendons: R L (Suppl 1):S33–S38. dinitis, experimental and clinical report. Vet Res Commun 2008;32 kuk D, Goulet M, Tremblay J. Transplanted myoblasts can migrate ampaolesi M, Blot S, D’Antona G, et astides PS,Khan WS. Cell-basedtherapiesinmusculoskeletalinjuries: eçanha R,Bagno L,Baldanza Ribeiro M,et acitignola L, Crovace A, Rossi G, Francioso E. Cell therapy for ten ajada S, Mazakova I, Richardson JB, Ashammakhi N. J Tissue Eng enzi S,RiccòDotti S,et ieira NM, Brandalise V, Zucconi E, Secco M, Strauss BE, Zatz M. rampera M, Pizzolo G, Aprili G, Franchini M. Mesenchymal stem ixon AJ, Dahlgren Haupt LA, JL, Yeager AE, Ward DL. Effect of odwin EE, Young NJ, Dudhia J, Beamish IC,Smith RKW. ta S, Uehara K, Nozaki M, et ONLY

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FOR PERSONAL USE ONLY Article

Prospective case-control study of toe tip necrosis syndrome (TTNS) in western Canadian feedlot cattle

Chad Paetsch, Kent Fenton, Tye Perrett, Eugene Janzen, Ted Clark, Jan Shearer, Murray Jelinski

Abstract — A case-control study was conducted to investigate potential risk factors for toe tip necrosis syndrome (TTNS) in western Canadian feedlot cattle. Feedlot veterinarians provided hooves from 222 animals that died of either TTNS (“cases”) or from all other causes (“controls”). The claws were sectioned by researchers to confirm the diagnoses; there was very good agreement between the practitioners’ field diagnosis and that of the researchers (Cohen’s kappa = 0.81; P , 0.001). The sole thickness of the apical white line region was thinner (P , 0.001) in the cases (3.74 mm) than the controls (4.72 mm). Claws from cases were 5.0 [95% confidence interval (CI): 1.5 to 8.6; P , 0.001] and 7.3 times (95% CI: 1.5 to 69.3; P , 0.01) more likely than those of controls to yield a heavy growth of Escherichia coli and Trueperella pyogenes, respectively. Cases were 4.4 times (95% CI: 4.4 to 22.9; P , 0.001) more likely to be acutely/transiently infected with bovine viral diarrhea virus than were controls. The findings support the hypothesis that TTNS is initiated by excessive wear along the white line, leading to separation and bacterial colonization of the 3rd phalangeal bone (P3) and associated soft tissues.

Résumé — Étude prospective de cas-témoins du syndrome de la nécrose du bout des orteils dans un parc d’engraissement de l’Ouest canadien. Une étude de cas-témoins a été réalisée pour investiguer les facteurs de risques potentiels pour le syndrome de la nécrose du bout des orteils (SNBO) chez le bétail des parcs d’engraissement de l’Ouest canadien. Les vétérinaires des parcs d’engraissement ont fourni des sabots provenant de 222 animaux qui sont morts soit du SNBO («cas») ou d’autres causes («témoins»). Les ongles ont été sectionnés par les chercheurs pour confirmer les diagnostics; il y avait une très bonne concordance entre le diagnostic sur le terrain des praticiens et celui des chercheurs (Kappa de Cohen = 0,81; P , 0,001). L’épaisseur de la sole dans la région de la ligne blanche atypique était plus mince (P , 0,001) dans les cas (3,74 mm) que dans les témoins (4,72 mm). Il était 5,0 fois (IC de 95 % de 1,5 à 8,6; P , 0,001) et 7,3 fois (IC de 95 % de 1,5 à 69,3; P , 0,01) plus probable que les ongles des cas donnent une croissance importante d’Escherichia coli et de Trueperella pyogenes, respectivement. Il était 4,4 fois (IC de 95 % de 4,4 à 22,9; P , 0,001) plus probable que les cas soient infectés de manière aiguë ou transitoire par le virus de la diarrhée virale des bovins comparativement aux témoins. Les résultats appuient l’hypothèse que le SNBO est amorcé par une usure excessive le long de la ligne blanche, ce qui entraîne une séparation et la colonisation bactérienne de l’os de la troisième phalange (P3) et des tissus mous connexes. (Traduit par Isabelle Vallières) Can Vet J 2017;58:247–254

Introduction came from Sick et al in 1982 (2), wherein they described the he mean (median) incidence of lameness in American clinical signs, treatment options, and postmortem findings of T feedlots has been estimated to be at 3.8% (2.0%), with the disease. Furthermore, they speculated that toe abscesses the 3 most common causes of lameness being interdigital were more common in high-spirited animals; animals shipped necrobacillosis (footrot), traumatic injury, and toe abscesses in aluminum trailers without sufficient bedding; and animals (1). One of the earliest reports of toe abscesses of feedlot cattle exposed to concrete surfaces. The disease also tended to affect

Paetsch Veterinary Services, Muenster, Saskatchewan (Paetsch); Feedlot Health Management Services, Oktotoks, Alberta (Fenton, Perrett); Production Animal Health, University of Calgary Faculty of Veterinary Medicine, Calgary, Alberta (Janzen, Clark); Veterinary Diagnostic and Production Animal Medicine, College of Veterinary Medicine, Iowa State University, Ames, Iowa, USA (Shearer); Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Saskatchewan (Jelinski). Address all correspondence to Dr. Murray Jelinski; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

CVJ / VOL 58 / MARCH 2017 247 FOR PERSONAL USE ONLY ARTICLE

Figure 2. Plantar surface of a claw showing white line separation and excessive wear at the apex of the toe.

Figure 1. Sagittal section of a claw taken from a control animal. abscesses, more recently, researchers have suggested a more encompassing term — toe tip necrosis syndrome (7–9). This the lateral digit of the hind limb and it was posited that exces- terminology not only describes the main clinical findings (toe sive wear to the apex of the toe resulted in white line separation, tip necrosis), but the term “syndrome” includes the sequelae bacterial invasion, and abscess formation. associated with the inciting lesion. Sick et al’s report (2) was followed by a second in 1994, A number of theories have been postulated for the cause of wherein Miskimins (3) described an unusual occurrence of the disease; however, the “abrasion theory” is perhaps the main- toe abscesses in mid-western US feedlots during the winter of stream theory. This theory proposes that excessive wear along the 1992 to 1993. Most cases developed within 3 wk after arrival apical white line leads to white line separation and subsequent at the feedlot and the affected animals had excessive wear along bacterial invasion of the claw. Lameness is probably manifested the apex of the hind toes, which was associated with white line when the infection reaches the corium (coriitis), and becomes separation and toe abscess formation. It was speculated that wet intractable once P3 becomes infected. In addition to the abra- weather conditions may have led to softening of the horn tissue, sion theory, others have suggested that excessive standing dur- resulting in excessive wear of the sole. Prolonged standing and ing processing and transport may lead to vascular disturbances exposure to concrete surfaces were also considered to be risk that result in ischemic necrosis of the P3 bone (10). However, factors for the disease. current research suggests that the lesion begins with white line Outbreaks of toe abscesses, however, are not unique to North separation and progresses into the claw versus moving from American feedlot cattle. In 1979, Dewes (4) described an out- P3 outwards (8). Veterinary pathologists have also noted that break of “transit-related lameness” in a group of Jersey replace- there is anecdotal evidence to suggest that bovine viral diarrhea ment heifers in New Zealand. Significantly, the toe lesions virus (BVDV) may be a risk factor for the disease. developed within 3 wk of transport, only involved the hind This is a companion paper to a previous study in which the toes, and toe abscesses were associated with white line separa- epidemiology of TTNS was described (9). The descriptive epi- tion. Dewes attributed the disease to the os pedis being forced demiological study identified a number of potential risk factors through the sole during transport. Van Amstel and Shearer (5) for TTNS, which were investigated in the present prospective have also described the occurrence of toe abscesses in North case-control study. American dairy cattle and have suggested that the distance to the milk parlour, exposure to new (“green”) concrete, and social Materials and methods factors such as commingling are potential risk factors for the Sample collection disease. More recently, Mason et al (6) described an outbreak of Three veterinary practices in Alberta, Canada participated in toe abscesses in New Zealand dairy heifers; however, lameness this prospective case-control study, which extended over a 2-year was not associated with transport, but rather with the heifers period, 2012 to 2013 and 2013 to 2014. The cases and controls being exposed to wet coarse concrete and being commingled were identified during field postmortem examinations. The case with cows. definition for toe tip necrosis syndrome (TTNS) was evidence Common to all these outbreaks is the finding of white line of white line separation and gross pathological involvement of separation, toe abscesses, and sequelae that include osteitis of P3. A control animal was the next animal to be necropsied, but the 3rd phalanx (P3); osteomyelitis of the 2nd phalanx (P2); without having gross pathology of P3. Control animals could ascending tenosynovitis and cellulitis; septicemia; and embolic be from a different cohort of cattle, but had to be similar in events involving the lungs, liver, and kidneys. Although feedlot the number of days on feed (DOF), body weight, and age class producers and veterinarians often refer to the disease as toe (calf or yearling).

248 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY ARTICLE

Figure 3. Sagittal section of a toe taken from an animal with early stages of toe tip necrosis syndrome. Note the separation Figure 4. Claw morphometric parameters: A — thickness of of the white line at the apex of the toe along with the necrotic dorsal hoof capsule at midpoint between periople and apex; material and organic debris located in this same area. The toe B — thickness of dorsal hoof wall capsule at solar corium; tip laminae have a frayed appearance and all visible laminae are C — thickness of sole at the white line; D — thickness of sole congested. at sole-heel junction; E — thickness of sole at plantar aspect of pedal bone; a = angle of outer dorsal hoof wall and sole; b = angle of inner dorsal hoof wall and sole; c = angle of dorsal Figure 1 is a sagittal section of a claw taken from a control aspect of pedal bone and sole; d = angle of dorsal and ventral animal. Note the uniform thickness of the sole, particularly at pedal bone. the tip of the toe. Figure 2 shows the plantar surface of the hoof of an animal with TTNS; the toe is rounded and there is white line separation. Figure 3 illustrates an early case of TTNS with (PDS; Saskatoon, Saskatchewan) and cultured on blood agar necrotic debris and organic material located along the white and MacConkey agar plates (Becton Dickinson and Company). line. The tip of the toe is also rounded and the apex of P3 has Agar plates were incubated at 37°C in 5% CO2 and also under a darkened mottled appearance. anaerobic conditions for a maximum of 48 h. Bacterial cultures Veterinary practitioners were instructed to collect the follow- were identified using standardized biochemical tests (12). The ing samples from each case and control animal: hooves, heart, dilution streak method was used as a semi-quantitative method and skin. The hooves were stored under refrigeration, and then for bacterial growth, with growth being categorized as: “few,” shipped by courier in an insulated cooler to researchers at the 11, 21, 31, and 41 (13). Western College of Veterinary Medicine (WCVM) where they were stored at 220°C until processing. The heart (papillary Immunohistochemistry for BVDV and muscle and septum) and skin samples were preserved in 10% Histophilus somni neutral buffered formalin. Heart samples were submitted to PDS for immunohistochemical (IHC) testing for the presence of bovine viral diarrhea virus Claw morphometric parameters (BVDV) and Histophilus somni specific antigens. Tests for At the WCVM the field diagnosis was confirmed by sectioning BVDV were also conducted on skin samples. These 2 antigens the hoof samples with a band saw. A thin sagittal section, 1.0 to were chosen because BVDV is known to cause immunosuppres- 2.0 cm thick, was sectioned and used for the morphometric sion, whereas H. somni is associated with causing a vasculitis. analyses. The cut surfaces were swabbed for microbiological Personnel from PDS were blinded with respect to which samples testing. were cases versus controls. Digital photographs (Nikon CoolPix L810; Nikon Canada, Immunohistochemical (IHC) staining for BVDV was con- Mississauga, Ontario) were taken of the thin sections and ducted using a commercial staining platform (Benchmark uploaded onto image processing software (Fiji continuous release staining platform; Ventana Medical Systems, Tuscon, Arizona, open source software) (http://fiji.sc/Fiji), which was used to USA) and an HRP-labelled multimer detection system (BMK calculate 9 morphometric claw measurements: 5 sole and hoof Ultraview DAB Paraffin detection kit; Ventana Medical wall thickness measurements and 4 hoof angle measurements Systems). Enzymatic epitope retrieval was performed (Protease 3; (Figure 4). The angle measurements were used to assess for Ventana Medical Systems) and the primary antibody (Mouse P3 rotation (11). anti-BVD clone 15c5) was applied for 32 min at a dilution of 1:500 (14). Weak staining for BVDV in the heart, without Bacterial culture a strong positive reaction from the skin was interpreted as an Aerobic and anaerobic culture swabs (BBL CultureSwab; Becton, acute (transient) BVDV infection, while strong positive reactions Dickinson and Company; Sparks, Maryland, USA) were used from the skin and heart were interpreted as the animal being to sample the sectioned surfaces of the pedal bone. Care was persistently infected (PI). taken to avoid contaminating the cut surface prior to swabbing. Immunohistochemical staining of the heart tissues for These samples were submitted to Prairie Diagnostic Services H. somni was conducted with an automated slide stainer

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Table 1. Number (%) of samples identified as cases and controls test was used if 1 or more cells in the contingency table had an by the field veterinarians versus the WCVM researchers expected frequency of # 5. The two-sample t-test was used to WCVM assess for differences between the cases and controls with respect Control Case to each of the 9 morphometric claw measurements. The level of (%) (%) Total significance for all statistical analyses was P , 0.05 (two-tailed). Field Control 80 (95.2) 4 (4.8) 84 Results Case 14 (13.6) 89 (86.4) 103 Three veterinary practices provided 222 submissions from Total 94 (50.3) 93 (49.7) 187 16 feedlots. Practitioners provided a diagnosis for 201 of the

ARTICLE submissions, while WCVM researchers were able to make a definitive diagnosis on 199 submissions. There were 187 submissions that had a diagnosis from both practitioners and research- (CodeOn Histomatic Stainer; Fisher Scientific, Edmonton, ers (Table 1). Assuming the WCVM diagnoses to be the “gold Alberta). Following pretreatment and enzymatic epitope retrieval, standard,” the positive (PPV) and negative predictive values sections were incubated overnight at 4°C with a rabbit poly- (NPV) were 86.4% and 95.2%, respectively. There was very clonal antibody (Vaccine and Infectious Disease Organization, good agreement between the practitioners and researchers with Saskatoon, Saskatchewan) (15). Binding of the primary antibody respect to categorizing the submissions as cases versus controls was detected using biotinylated immunoglobulins (Vector Labs, (k = 0.81; P , 0.001). Burlington, Ontario) and an avidin-biotin immunoperoxidase complex reagent (Vector Labs), with 3,39-diaminobenzidine tet- Claw morphometric measurements rahydrochloride (Electron Microscopy Science, Fort Washington, Table 2 is a summary of the descriptive statistics for the claw Pennsylvania, USA) as the chromogen. morphometric measurements. The sole thickness at site “C” (apical white line) was thinner in the cases than the controls Examination for vasculitis (P , 0.001), with a similar trend (P = 0.06) at site “D.” There The formalized heart samples were sectioned, embedded in were no differences in the mean angle measurements taken from paraffin, stained with hematoxylin and eosin (H&E), and a vet- the cases and controls. erinary anatomic pathologist used light microscopy to examine the heart samples for vasculitis, perivasculitis, and periarteritis. Bacterial testing This testing was undertaken because it was hypothesized that A total of 230 swabs (122 cases and 108 controls) were submit- vasculitis of the corium may contribute to TTNS. Furthermore, ted for microbiological testing. The number of swabs exceeds the because the corium is difficult to process for histological testing, number of cases and controls because aerobic swabs were taken it was assumed that if the heart had vasculitis, then there may from all the cut claw surfaces, and a smaller subset of anaerobic also be a generalized vasculitis involving the corium. culture swabs was also submitted. In addition, in some instances more than one claw was affected, and hence all affected claws Data analyses were swabbed. Overall, across all isolates, the samples from cases Data were entered into a relational database (Microsoft Access were 2.5 times (95% CI: 1.4 to 4.3; P = 0.001) more likely than v. 14; Microsoft Corporation, Redmond, Washington, USA) and those from the controls to result in a heavy growth of bacteria. exported to a commercial spreadsheet program (Microsoft Excel Figure 5 shows the number of heavy growth isolates, by bac- v. 12; Microsoft Corporation) for generating the descriptive terial species, recovered from the case and control claws. Cases statistics. The data were subsequently exported to a statistical were 5.0 times (95% CI: 1.5 to 8.6; P , 0.001) more likely program, SPSS (Version 20, SPSS, Chicago, Illinois, USA) for than the controls to have a heavy growth of Escherichia coli and further analyses. 7.3 times (95% CI: 1.5 to 69.3; P , 0.01) more likely to have The Cohen’s kappa test statistic compared the inter-rater a heavy growth of Trueperella pyogenes. agreement between the practitioners’ diagnoses to those made by researchers at the WCVM. The positive predictive value Immunohistochemistry and microscopic (PPV) and negative predictive value (NPV) were calculated for examination the field diagnoses. Table 3 provides the breakdown of the number (percent) of cases The microbiological results were provided as semi- and controls that were either acutely or persistently infected (PI) quantitative data (no growth, “few,” 11, 21, 31, and 41) and with BVDV. There were 188 heart samples tested for BVDV, but then transformed into a dichotomous variable: “light growth” only 151 skin samples were collected and submitted. However, (few, 11 and 21) and “heavy growth” (31 and 41). Separate the 37 heart samples for which there was no corresponding Chi-square analyses were used to determine whether the cases skin sample all tested negative for BVDV. Cases were 4.4 times and controls were associated with a particular dichotomous more likely to have an acute BVDV infection than were the outcome: light or heavy bacterial growth; positive or negative controls (P , 0.001); however, there was no statistical differ- IHC results from the skin and heart for BVDV (acute and per- ence with respect to being PI (Fisher Exact Test P = 0.12). There sistently infected); positive or negative IHC results for H. somni; was a strong trend for the cases to have evidence of a cardiac and microscopic evidence of a cardiac vasculitis. Fisher’s exact vasculitis (P = 0.07). All BVDV positive animals, both acutely

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Table 2. Descriptive statistics for claw morphometric measurements Standard Variable Mean Median deviation Maximum Minimum P-value Site A (mm) Case (n = 64) 4.65 4.60 1.12 8.20 2.56 0.62 Control (n = 63) 4.75 4.69 0.93 6.79 2.50 —

Site B (mm) ARTICLE Case (n = 62) 5.04 5.24 1.32 8.71 2.50 0.31 Control (n = 61) 5.27 5.22 1.26 8.79 2.84 — Site C (mm) Case (n = 64) 3.74 3.66 1.14 7.42 1.14 , 0.001 Control (n = 60) 4.72 4.77 1.25 8.05 1.91 — Site D Case (n = 63) 3.44 3.28 0.78 5.69 2.11 0.06 Control (n = 60) 3.78 3.47 1.22 8.13 2.04 — Site E Case (n = 63) 5.71 5.71 1.22 8.65 3.65 0.76 Control (n = 62) 5.64 5.60 1.32 9.37 3.29 —

Angle a (°) Case (n = 64) 56.86 56.43 4.75 68.83 44.39 0.14 Control (n = 62) 58.12 57.83 5.19 72.45 47.83 — Angle b (°) Case (n = 64) 58.26 57.54 5.03 69.97 43.77 0.54 Control (n = 62) 58.78 57.74 4.87 71.46 49.62 — Angle c (°) Case (n = 63) 58.20 58.54 5.99 72.92 39.76 0.88 Control (n = 62) 58.35 57.48 4.90 69.38 48.09 — Angle d (°) Case (n = 64) 52.10 51.71 6.46 69.96 36.77 0.10 Control (n = 62) 53.68 53.21 4.74 64.50 43.09 —

30 Controls Cases 25

5 Number of bacterial isolates 0

spp. spp. spp. spp. spp. spp. spp. E. coli Other

T. pyogenes Neisseria Bacteroides Enterobacter Pseudomonas Streptococcus Staphylococcus Corynebacterium Pseudomonas aeroginosa Fusobacterium necrophorum Bacterial isolates

Figure 5. Number of bacterial isolates, by species, that were cultured from the claws of the cases and controls and that yielded a “heavy” growth of bacteria (N = 123). infected and PI animals, were 10.0 times (95% CI: 4.4 to 22.9; Discussion P , 0.001) more likely to have a vasculitis than were the BVDV There was very good agreement between the practitioners’ diag- negative animals. noses and that of the researchers; cases and controls were cor- Immunohistochemistry for H. somni was performed on the rectly identified 86% and 95% of the time, respectively. Some first 42 cardiac muscle samples; however, only 1/11 (9.1%) discrepancies in the diagnoses may be related to simple mis controls and 1/31 cases (3.2%) tested positive for H. somni labeling of the field samples by the field veterinarians. However, (P = 0.46). Both positive animals had a vasculitis, but both were there were also instances in which claws identified as cases by the BVDV negative. Due to the very low prevalence of H. somni, field veterinarians had evidence of white line separation, but no further tests were not conducted. P3 involvement and hence they did not meet the case definition.

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Table 3. Samples from the cases and controls that were either acutely or persistently infected (PI) with bovine viral diarrhea virus (BVDV) 95% CI Test Result Case (%) Control (%) OR Lower Upper P-value BVDV Acute Positive 43 (45.7) 15 (16.0) 4.4 2.2 8.8 , 0.001 (n = 188) Negative 51 (54.3) 79 (84.0) — — — — BVDV PI Positive 7 (8.6) 2 (2.9) 3.2 0.65 16.1 0.12 (n = 151) Negative 74 (91.4) 68 (97.1) — — — — Vasculitis Positive 22 (23.4) 13 (13.8) 1.9 0.89 4.05 0.07 ARTICLE (n = 188) Negative 72 (76.6) 81 (86.2) — — — —

In other instances, the foot lesions initially appeared similar to phase of ambulation. This opening and closing action allows toe tip necrosis syndrome (TTNS) lesions; however, upon closer bacteria-laden organic debris to become impacted in the apex of inspection there was no white line separation and pathological the claw, explaining the heavy growth of E. coli and T. pyogenes. changes affecting P3 were attributed to a penetrating foreign Significantly, T. pyogenes is a facultative anaerobe that thrives in body. There was, however, excellent agreement when it came to both aerobic and anaerobic conditions and is associated with the classification of the controls; only 4 claws submitted as con- abscess formation. Presumably, following colonization, the bac- trols were in fact cases. The findings highlights that most cases teria migrate along the white line, breach the highly vascularized and controls can be reliably diagnosed under field conditions. corium, and then infect the poorly vascularized P3 bone and There was no evidence from the hoof angle measurements of soft tissues of the hoof. P3 rotation. However, the sole in the apical white line region The other finding of interest was the association between was thinner in the TTNS cases than the controls, and there BVDV and TTNS, and hence some additional discussion is was a very strong trend for thinning in the area of the sole-heel warranted with respect to how the testing was conducted as junction. These findings are in agreement with previous reports well as the interpretation of the results. The utility of immuno- of excessive wear occurring along the leading edge of the toes histochemical (IHC) testing for detecting persistently infected (2,3). The significance of this finding is that it supports the (PI) BVDV animals has been well-established (15,17,18). “abrasion theory,” wherein the disease is initiated when cattle While the sensitivity of IHC testing for identifying PI animals develop excessive wear along the apical and abaxial regions of is nearly 100%, its specificity is slightly lower because acutely the white line. As a consequence, the integrity of the white line (transiently) infected animals may appear indistinguishable from is reduced, allowing bacteria to penetrate the hoof capsule and PI animals (19). This is less of an issue when testing live animals infect the underlying structures. because retesting at a later date can distinguish false positives Because the disease is assumed to be initiated by excessive from the true positive PI animals (20). Unfortunately this option wear along the apex of the toes, this part of the theory deserves does not exist when testing dead animals. Therefore, in the cur- further elaboration. The white line is composed of 3 parts or rent study, an animal was considered to be acutely (transiently) zones: outer, intermediate, and inner (16). This is salient because infected if BVDV antigen was present in the heart, but not in the horn tissue of each zone is produced by different laminae the skin. On the other hand, a strong reaction to the antigen in (dermis), resulting in horn with distinctly different structural both the heart and skin samples was interpreted as the animal properties. Therefore, the white line is not a homogenous tis- being PI. Heart tissues were chosen because BVDV is known to sue, but rather a composite of tissues. As a result, the white infect the heart tissue of experimentally (acutely infected) chal- line is an inherent weakness in the hoof capsule, the “Achilles’ lenged calves (21,22). It was also convenient to use heart tissue heel,” so to speak. Referring to Figure 1, the white line resides because the field veterinarians were collecting heart tissue for at the intersection of the sole and the hoof wall, and it is not H. somni testing and histopathological examination. too difficult to appreciate that abrasion of the solar horn at the With respect to the BVDV findings, 2.9% of the control apex of the toe would reduce the length of the white line, lead- calves in the current study were PI animals, which is similar ing to a loss in its structural integrity. Once compromised, it is to a previous feedlot study wherein 2.5% of all dead animals hypothesized that the repetitive cycling of weight-bearing forces, were PI (23). Although 8.6% of the TTNS animals were PI, during the act of ambulation, would lead to the propagation the prevalence of PI animals in the cases and controls was not of micro-fissures along the outer zone of the white line. These statistically significant (P = 0.12). However, this deserves addi- fissures would lead to further weakening along the white line, tional research since the lack of association may be related to a eventually culminating in complete separation of the outer zone lack of statistical power. from the intermediate zone. While the association between PI status and TTNS was Organic materials such as shards of macerated straw were equivocal, TTNS cases were 4.4 times more likely to be acutely occasionally found embedded within the white line of the claws infected with BVDV than were the controls. Furthermore, obtained from TTNS animals. This begs the question as to how the BVDV positive animals were 10 times more likely than this material penetrated the white line. The most likely explana- the BVDV negative animals to have histological evidence tion is that the white line gapes open during the load-bearing of a cardiac vasculitis. This latter association is of particular

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interest because researchers have speculated that BVDV may mustered in pens, cattle liners, and as they move through chutes. evoke a vasculitis (24). If so, then an acute BVDV infection During these scenarios the cattle frequently push and strain may have initiated a generalized vasculitis involving the highly against the animals ahead of them. If forces generated by the vascularized corium (dermis). Nutrients and hormones diffuse muscular hind limbs exceed the coefficient of friction, then the from the highly vascularized dermis into the non-vascularized claws lose traction and the course abrasive flooring acts like a epidermis, and hence homeostasis of this diffusion gradient rasp to remove the horn tissue; torsional forces may also lead

is critical to the development of healthy horn tissue (25,26). to tearing or separation along the white line. Therefore, the ARTICLE Conceivably, a BVDV-induced vasculitis of the dermal vas- inciting event is probably short in duration, extremely forceful, culature could disrupt normal perfusion, leading to a loss and the abrasion of the solar horn is primarily localized to the of integrity along the white line, contributing to white line apical region of the toe. separation. This pathogenesis would be similar to laminitis, If the disease is left unattended in both dairy and feedlot which is also thought to arise from impaired perfusion of the cattle, then the endpoint is probably the same: toe abscesses, corium (27). infection along the white line, P3 osteitis, and other sequalae An alternate explanation for the association between BVDV such as tenosynovitis and embolic pneumonia. However, dairy and TTNS may be related to immunosuppression. Bovine viral animals are under constant surveillance and lame animals are diarrhea virus is known to cause immunosuppression (28,29) often identified and treated early in the course of the disease. and is considered a risk factor for feedlot diseases such as In contrast, TTNS occurs early in the feeding period and the bovine respiratory disease (30). Therefore, bacterial invasion disease clusters in the fall of the year when feedlots are extremely and colonization of the white line may be more likely to occur busy processing new arrivals and dealing with other diseases such in immunocompromised animals, which may lead to a fulmi- as bovine respiratory disease. Therefore it is more challenging to nant infection culminating in death. It must, however, also be identify cattle in the early stages of lameness, and even if they recognized that association is not synonymous with causation. are identified, most operations are ill-equipped to perform a Perhaps the TTNS animals were more likely to be exposed in proper lameness examination. Lame animals would typically the hospital pens to other sick animals who were shedding receive antimicrobials, but no other ancillary treatment such as BVDV. In this scenario, the transient BVDV infections may debriding the ulcer and bandaging the foot. Animals that fail have developed after TTNS. Finally, although there was a strong to respond to antimicrobial therapy either die naturally or are association between acute BVDV infections and TTNS, BVDV euthanized due to intractable lameness. As a result, it is this was not a necessary cause for the disease; 50% of TTNS cases population of TTNS cases that feedlot veterinarians are most were BVDV negative. likely to see, which bear no resemblance to the early developing While TTNS has been described in dairy animals (4,6), this TSTU condition of dairy cattle. disease is primarily a disease of feedlot cattle. Care must be taken Although the two diseases have a number of features in com- not to confuse TTNS with the commonly encountered thin sole mon, it would be presumptuous to conclude that they are in fact toe ulcers (TSTU) of dairy cattle (31). Both TSTU and TTNS the same disease. While characterizing the white line separation are associated with thinning of the soles, the lesions occur in as either separation along the outer as opposed to the inner zone the same general regions of the claw, both involve white line may seem overly specific, this detail must not be overlooked, and separation, and in advanced cases the lesions progress to abscess hence more research is required to gain a better understanding formation and P3 osteitis. However, in TTNS the separation of the pathogenesis of TTNS. CVJ of the white line appears to be occurring along the outer zone of the white line, whereas in TSTU the sole is separating away References from the inner zone of the white line. At this point, it is dif- 1. Terrell SP, Thomson DU, Reinhardt CD, Apley MD, Larson CK, ficult to determine whether the 2 diseases are distinct and have Stackhouse-Lawson KR. Perception of lameness management, edu- different etiologies and pathogeneses, or whether it is the same cation, and effects on animal welfare of feedlot cattle by consulting disease but manifested in 2 different manners. nutritionists, veterinarians, and feedlot managers. Bovine Practitioner 2014;48:53–60. If the 2 diseases are in fact related, then the different clinical 2. Sick FL, Bleeker CM, Mouw JK, Thompson WS. Toe abscesses in presentations of the disease may be related to temperament, recently shipped feeder cattle. Vet Med Small Anim Clin 1982;77: facilities, and cattle handling. Dairy cattle are relatively docile, 1385–1387. 3. Miskimins DW. Bovine Toe Abscesses. Proc 8th International but are also exposed to more concrete and wetter environmental Symposium on Disorders of the Ruminant Digit, Banff, Alberta 1994: conditions, risk factors that lead to increased wear over a period 54–57. of weeks to months. In contrast, the more temperamental feed- 4. Dewes HF. Transit-related lameness in a group of Jersey heifers. N Z Vet J 1979;27:45. lot cattle are raised in earthen-floored pens and hence exposure 5. Van Amstel SR, Shearer JK. Toe abscess: A serious cause of lameness in of their hind feet to concrete and other hard abrasive surfaces the US dairy industry. Proc. XI Interantional Symposium on Disorders occurs over a relatively short period at the time of transport, at of the Ruminant Digit, Parma, Italy 2000:212–214. 6. Mason WA, Laven LJ, Laven RA. An outbreak of toe ulcers, sole ulcers auctions, and during processing at feedlots. Although feedlot and white line disease in a group of dairy heifers immediately after cattle have less contact with abrasive surfaces than do dairy calving. N Z Vet J 2012;60:1:76–81. cattle, both their temperament and how they are handled may 7. Paetsch CD, Jelinski MD. Toe-tip necrosis syndrome in feedlot cattle in western Canada. Proc 17th International Symposium and lead to abrasion of the apex of the toe. It is not uncommon to 9th International Conference on Lameness in Ruminants, Bristol, UK see feedlot cattle being overcrowded and agitated while being 2013:152–153.

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8. Gyan LA, Paetsch CD, Jelinski MD, Allen AL. The lesions of toe tip buffy coat virus isolation for detection of calves persistently infected necrosis in southern Alberta feedlot cattle provide insight into the with bovine viral diarrhea. J Vet Diagn Invest 2005;17:110–117. pathogenesis of the disease. Can Vet J 2015;56:1134–1139. 21. Spagnuolo-Weaver M, Allan GM, Kennedy S, Foster JC, Adair BM. 9. Jelinski MD, Fenton K, Perrett T, Paetsch CD. Epidemiology of toe tip Distribution of cytopathic and noncytopathic bovine viral diarrhea virus necrosis syndrome (TNNS) involving North American feedlot cattle. antigens in tissues of calves following acute experimental infection. J Vet Can Vet J 2016;57:829–834. Diagn Invest 1997;9:287–297. 10. Greenough PR, ed. Bovine Laminitis and Lameness: A Hands-On 22. Liebler-Tenorio EM, Ridpath JF, Neill JD. Distribution of viral antigen Approach. 1st ed. Philadelphia, Pennsylvania: Saunders Elsevier, and development of lesions after experimental infection with highly 2007:100–102. virulent bovine viral diarrhea virus type 2 in calves. Am J Vet Res 2002; 11. Sloet van Oldruitenborgh-Oosterbaan MM. Laminitis in the horse: 63:1575–1584. A review. Vet Quart 1999;21:121–127. 23. Loneragan GH, Thomson DU, Montgomery DL, Mason GL, Larson RL. 12. Quinn PJ, Markey B, Leonard FC, Fitzpatrick ES, Fanning S, Prevalence, outcome, and health consequences associated with persistent

ARTICLE Hartigan PJ. Veterinary Microbiology and Microbial Disease. 2nd ed. infection with bovine viral diarrhea virus in feedlot cattle. J Am Vet Med West Sussex, UK: Wiley-Blackwell, 2011:179–405. Assoc 2005;226:595–601. 13. Carter GR. Clinical Veterinary Microbiology. 9th ed. St. Louis, 24. Désilets A, Montpetit C, Trépanier H, Archambault D. BVDV Missouri: Mosby, 1993. Infection: Five possible pathogenesis mechanisms related to the devel- 14. Barry AL. Clinical specimen for microbiologic examination. In: opment of Type III hypersensitivity lesions in BVDV infected animals. Hoeprich P, ed. Infectious Disease: A Guide to the Understanding and Proceedings International Symposium, Bovine Viral Diarrhea Virus: Management of Infectious Process. New York, New York: Harper and A 50 year review, Cornell University, Cornell, New York 1996:192. Ron Publishing, 1972:103–107. 25. Tomlinson DJ, Mülling CH, Fakler TM. Invited review: Formation of 15. Haines DM, Moline KM, Sargent RA, Campbell JR, Myers DJ, Doig keratins in the bovine claw: Roles of hormones, minerals, and vitamins PA. Immunohistochemical study of Hemophilus somnus, Mycoplasma in functional claw integrity. J Dairy Sci 2004;87:797–809. bovis, Mannheimia hemolytica, and bovine viral diarrhea virus in death 26. Mülling CH, Bragulla HH, Reese S, Budras K-D, Steinberg W. How losses due to myocarditis in feedlot cattle. Can Vet J 2004;45:231–234. structures in bovine hoof epidermis are influenced by nutritional factors. 16. Shearer JK, Plummer PJ, Schleining JA. Perspectives on the treatment Anat Histol Embryol 1999;28:103–108. of claw lesions in cattle. Vet Med Res Reports 2015;6:273–292. 27. Hendry KAK, MacCallum AJ, Knight CH, Wilde CJ. Review article: 17. Njaa BL, Clark EG, Janzen E, Ellis JA, Haines DM. Diagnosis of per- Laminitis in the dairy cow: A cell biological approach. J Dairy Res 1997; sistent bovine viral diarrhea virus infection by immunohistochemical 64:475–486. staining of formalin-fixed skin biopsy specimens. J Vet Diagn Invest 28. Chase CCL. The impact of BVDV infection on adaptive immunity. 2000;12:393–399. Biologicals 2013;41:52–60. 18. Brodersen BW. Immunohistochemistry used as a screening method for 29. Lanyon SR, Hill FI, Reichel MP, Brownlie J. Bovine viral diarrhea: persistent bovine viral diarrhea virus infection. Vet Clin Food Anim Pathogenesis and diagnosis. Vet J 2014;199:201–209. 2004;20:85–93. 30. Ridpath J. The contribution of infections with bovine viral diarrhea 19. Dubovi EJ. Laboratory diagnosis of bovine viral diarrhea virus. Bio viruses to bovine respiratory disease. Vet Clin Food Anim 2010;26: logicals 2013;41:8–13. 335–348. 20. Cornish TE, van Olphen AL, Cavender JL, et al. Comparison of ear 31. Shearer JK, van Amstel SR. Toe lesions in dairy cattle. Proceedings 46th notch immunohistochemistry, ear notch antigen-capture ELISA, and Florida Dairy Production Conference, Gainsville, Florida, 2009:47–55.

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254 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY Article

Conceptualization of convenience euthanasia as an ethical dilemma for veterinarians in Quebec

Dominick Rathwell-Deault, Béatrice Godard, Diane Frank, Béatrice Doizé

Abstract — Companion animal welfare in our society has become increasingly important, yet many healthy animals are euthanized in veterinary facilities. How is it possible to explain the simultaneous presence of these opposing views of obligation toward animals? The goal of this study was to describe convenience euthanasia of companion animals as experienced by veterinarians in order to understand their thought processes. A qualitative study was undertaken to analyze the results of interviews of 14 veterinarians. The study showed that veterinarians interviewed assessed convenience euthanasia based mainly on their subjective evaluation of the owner-animal bond. As most owner-animal bonds stem from an anthropocentric point of view, decisions on convenience euthanasia were taken mostly by considering the veterinarian’s and the client/owner’s interests.

Résumé — Conceptualisation de l’euthanasie pour des raisons de commodité comme dilemme éthique pour les vétérinaires du Québec. Le respect du bien-être des animaux de compagnie dans notre société est devenu de plus en plus important. Fait paradoxal, beaucoup d’animaux en santé sont euthanasiés dans les établissements vétérinaires. Comment peut-on expliquer la présence concomitante de ces vues opposées à l’égard des obligations envers les animaux? Le but de cette étude consistait à décrire l’euthanasie des animaux de compagnie pour des raisons de commodité selon les expériences des vétérinaires afin de comprendre leurs processus de réflexion. Une étude qualitative a été entreprise afin d’analyser les résultats d’entrevues avec 14 médecins vétérinaires. L’étude a signalé que les vétérinaires interviewés évaluaient l’euthanasie pour des raisons de commodité surtout en se basant sur leur évaluation subjective du lien entre le propriétaire et l’animal. Comme la majorité des liens entre propriétaires et animaux découlent d’un point de vue anthropocentrique, les décisions pour l’euthanasie pour des raisons de commodité étaient prises surtout en considérant l’intérêt du médecin vétérinaire et du client/propriétaire. (Traduit par Isabelle Vallières) Can Vet J 2017;58:255–260

Introduction an animal has to belong to a caring human in order to receive thical dilemmas in the practice of veterinary medicine attention for its specific interests and needs. This last point E represent a situation in which 2 or more values are in illustrates the importance of the owner-animal bond. Rollin’s conflict and a decision is difficult to make (1,2). Core values are garage mechanic model (4) similarly describes the service orien- associated with perception of actions toward animals particularly tation of the veterinarian to his client. In the biocentric model, in cases of convenience euthanasia (defined as euthanasia of a animals are viewed as moral beings just like humans. Animals physically and psychologically healthy animal) (3). Two models are described as complete entities and the interests and needs of have been described in the literature, the anthropocentric- the animal are then considered a priority. The biocentric vision biocentric model and the pediatrician-mechanic model (1,4). of animals shows an egalitarian position between the interests In the anthropocentric model, the animal is fundamentally and needs of animals and humans. Veterinarians perceiving described by the owner-animal bond. The interests and needs animals in a biocentric model tend to act like pediatricians (4). of animals are not directly taken into consideration. In fact, Veterinarians are no longer neutral professional service pr oviders.

Sciences cliniques (Rathwell-Deault), Médecine préventive et sociale (Godard), Centre Hospitalier Universitaire Veterinaire (Frank), Pathologie et microbiologie (Doizé), Université de Montréal Faculté de médecine vétérinaire, 1200 rue Sicotte, Saint Hyacinthe, Quebec J2S 7C6. Address all correspondence to Dr. Dominick Rathwell-Deault; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

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They are medical professionals acting as advocates to protect Probabilistic sampling would most likely unintentionally their patients. exclude veterinarians who were not practicing convenience The present study focused on the animal’s status in veterinary euthanasia, due to their low number. This sampling method medicine as well as the moral duties of veterinarians toward could therefore create a risk of obtaining incomplete results. animals. The role and consideration of each major stakeholder A non-probabilistic sampling method was therefore chosen. (owner, veterinarian, animal) regarding decisions about con- Veterinarians known to not practice convenience euthanasia venience euthanasia are core elements necessary for a better were solicited first, followed by veterinarians performing con- understanding of the dilemma. To date, there is little published venience euthanasia. This purposeful sampling (12) would on the topic (5–7). The Quebec licensing body for veterinarians likely result in a more efficient collection of in-depth informa-

ARTICLE (OMVQ: RLRQ c M-8, r 4) clearly defines and regulates duties tion about the dilemma. A snowball method was used to find concerning physical suffering and methods of euthanasia based participants (13). The snowball method was initiated with on species (8). Unfortunately, moral duties of veterinarians with 4 veterinarians from different backgrounds to ensure diversity regard to convenience euthanasia are not clearly defined within and representativeness of the data. the profession even though the American Veterinary Medical Initially, no limit on the number of participants was estab- Association (AVMA) has published euthanasia guidelines (8). lished. Data analysis was done throughout the period of data The most recent version (2013) now includes an algorithm to collection. This procedure allowed the researchers to evaluate, evaluate the morality of the decision. If animals belong to the on an on-going basis, if saturation of information had been sphere of moral beings as described by several authors (4,9,10) reached and to decide if additional interviews were needed. and the animal is taken into consideration, what thought pro- “Saturation achieves 2 main functions: from an operational cesses do veterinarians rely on to make daily decisions regard- standpoint, it tells the researcher when to stop data collection ing convenience euthanasia? In order to answer this question, to avoid useless collection of data and waste of time or money. a qualitative study on the subject of convenience euthanasia From a methodological standpoint, it allows generalization of was undertaken. The goal of this study was to describe con- results to the given population” (11). Fourteen 30- to 45-minute venience euthanasia of companion animals as experienced by interviews were completed. This sample size matched informa- veterinarians. tion in the literature about the average number of interviews usually required in non-probabilistic studies to reach saturation Materials and methods of information (14). Interviews were initiated on May 18, 2010 Methodological approach and concluded on November 18, 2011. A qualitative methodology (inductive approach) was best suited to obtain the most data. Semi-structured interviews of veteri- Data analysis narians were conducted to explore their perspective in depth. Interviews were recorded and transcribed (MSWord; Microsoft, The interviews consisted of open-ended questions followed by Redmond, Washington, USA). First, manual coding of the text a scheduled period of discussion on convenience euthanasia. (verbatim) was done to establish a preliminary list of codes The interview questions are available from the first author on (15,16). For example, if a veterinarian described her pet as equal request. The interview guide was pre-tested and no modifica- to a human, this section of text was coded “equal to human.” tion was necessary. This method allowed an exploration of the Once the manual coding of the first 4 interviews was com- issues at the heart of the dilemma (11). This study was approved pleted, the software program QDA MINER (Provalis Research, by the research ethical committee of the Faculty of Medicine Montreal, Quebec) was used for coding management of all at the University of Montreal. All participants signed written interviews. The coding list was continuously adjusted during the consent forms. entire data collection period. Next, 2 methods were performed to ensure internal validity and accuracy of the coding technique Population studied and sampling (11). The first consisted of counter-coding by an independent This research on the perception of the dilemma of convenience research assistant. Consistency level (percentage agreement) was euthanasia was limited to veterinarians in Quebec. Companion 89% (15,16). The second was inverse coding. Use of inverse animal practitioners are confronted with this dilemma and thus coding ensures that all interview excerpts represented by a code were selected for this study. No distinction was made between are appropriately categorized. These 2 methods of verification general practitioners and specialists. The sample included 1 spe- showed that the coding results were accurate. cialist and 13 general practitioners, and involved a wide range of A thematic analysis of the interviews was done to draw an initial clinical experience (2 to 32 y), men, women, owners, employ- portrait of the current situation. Thematic analysis was achieved ees, and rural and urban practices in 5 regions in Quebec. The by grouping codes to represent the main ideas expressed (17). purpose of this qualitative research was to take a wide range of possible opinions into consideration (divergent or not), to Results achieve data “saturation.” Veterinarians who accepted or refused Three primary/overarching themes emerged from the data: to practice convenience euthanasia were invited to participate. i) influence of the veterinarian’s personal and professional Only veterinarians refusing to practice convenience euthanasia perceptions of the animal on clinical decisions concerning con- for ethical reasons were classified in the group of veterinarians venience euthanasia; ii) origin of the convenience euthanasia not practicing convenience euthanasia. dilemma; and iii) veterinary involvement in this dilemma.

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Theme 1: Influence of the veterinarian’s animals, an example would be the garage dog and he is personal and professional perceptions of the a utility animal not really a companion. When we talk animal on clinical decisions concerning to those owners, they are telling us that the dog is only a convenience euthanasia garage dog kept outside and that they would not invest a Veterinarian’s perception of the companion animal in lot of money for his healthcare. As said before, for them his/her personal life the dog is only a utility animal. For most of the clients seen

Veterinarians were asked to discuss their perception of animals in clinic, animals are more than that; they are a companion ARTICLE in their personal life. Ten veterinarians gave enough informa- for different reasons. They are a companion because the tion about this topic to be assessed. Responses were classified in owner is lonely, because they want their children to have a 5 categories which were not mutually exclusive: i) being differ- friend, because the dog is always there to play with them.” ent from humans, ii) companion, iii) family member, iv) living The responses were divided into 6 categories which were not being, and v) equal to humans. mutually exclusive: i) member of the family equivalent to a Some veterinarians believed that animals were different from human member, ii) companion, iii) social crutch, iv) tangible humans (illustrated by all the previously listed categories except personal property, v) subordinate, and vi) utility. the category equal to humans). These veterinarians were not able Data analysis showed that within their professional context, to qualify this difference or to establish a comparison plan. They veterinarians perceived animals in 2 distinct ways. Either, vet- mostly thought that animals and humans belonged in separate erinarians presented a vision of the animal by describing the categories and therefore were impossible to compare: place of animals in a utility role in the relationship with the “Yes, completely different. I think that we do enjoy their pres- owner (all categories except “member of the family equivalent ence, probably as they enjoy ours. But we must be careful. to human member”) or the animal was described as a family This does not mean that they owe us something. Yes, we feed member equivalent to human member. them and take care of them, but they would be able to do it without us. They are not subordinate to us; it is different.” Evaluation of the relationship between the owner, animal, and veterinarian in cases of convenience None of the veterinarians agreed when confronted with a euthanasia classification that puts the animal at a lower level than humans. Veterinarians were asked to describe their perception of the rela- However, when the veterinarians thought of a familiar context tionship of the owner, animal, and veterinarian in the context in which the interest of their animal was in conflict with the of convenience euthanasia. Since not all convenience euthanasia interest of a family member, the animal’s interest was always situations were identical, a veterinarian could express diametri- considered after the family member’s interest: cally opposite opinions on the topic: “But my animal would never be considered ahead of a per- “I do my physical exam of the animal first and I talk with son that I love (…), there is a special place for my animal the client as if the animal was a young child unable to talk but it is not absolute.” on its own. Depending on the client’s reaction, I change Some veterinarians clearly defined their animal as their equal. my way of dealing with the case.” They justified their position by the absence of valid arguments Thirteen veterinarians gave enough information about this to allow a distinction to be made between humans and animals. topic to be assessed. The veterinarians were not questioned on This point of view is illustrated by the following comment: a specific situation. They chose their own context to define their “It always depends on what we base ourselves. If we vision. Veterinarians were invited to describe the situation in take life, then I think that we are all equal. We consider order to explain the priority of attention that they gave to the ourselves superior as humans, but I am not sure that we animal’s needs and those of the owner. Some veterinarians said deserve it. We may be superior in terms of cognitive capa- that they prioritized and respected the animal’s interests when bilities, but with regards to life and welfare, I am not sure.” they decided about euthanasia. “I decided to persist in the fact that I am here to do the Veterinarian’s perceptions of the client owner-animal best that I can for the animals and I will always do what bond is best for them. I stay polite and diplomatic with clients, An evaluation of the veterinarian’s perception of the animal but I studied to be able to treat animals, not to deal with during professional activities was possible through responses human psychology. And it will stay like that.” obtained from direct questioning. Thirteen veterinarians gave sufficient information about the topic. The responses were all Of those, some systematically refused to proceed with conve- related to the veterinarian’s perception of the owner-animal nience euthanasia. Some veterinarians, however, gave priority bond. As an illustration, here is the response of one veterinarian: to respecting the owner’s interest. These veterinarians always decided to proceed with convenience euthanasia. “I think that the animal does more now than before. For some people the animal can be a companion, we see this “At that moment, when people are here for euthanasia, the really often, but for others, the animal would always be importance should be put on them. The animal doesn’t seen as a utility animal. If we look only at companion matter anymore.”

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Some veterinarians explained that they tried to find a balance Veterinarians also felt that consumers had higher expectations between the animal’s interests and those of the owner. Data of their animals and the overabundance of available animals was obtained did not reveal an imperative scheme on how veterinar- amplifying the problem. Owner expectations were becoming ians consider the animal’s interests nor how they prioritize each more and more superficial and unrealistic. These owners became stakeholder’s interest when requested to perform convenience easily frustrated because they had an illusionary vision of what euthanasia. In fact, depending on the situation described, priori- their animal should be and do. They then rejected their animal tization of the interests fluctuated with the circumstances. For easily knowing that it would be simple to find another one that example, one veterinarian described a situation in which he had perhaps met their expectations. prioritized the animal’s interests and then described a different “Our level of satisfaction is so difficult to reach and our ARTICLE situation in which he had prioritized the owner’s interests. Few values about satisfactory criteria for beauty and other veterinarians were consistent in every situation and they always superficial topics are so difficult to address because there prioritized the animal’s interests by refusing to proceed with are so many choices available. It is the same thing with convenience euthanasia. animals. He was pretty and young, but now he is older and bigger and we are less attached to him. We need to Theme 2: Origin of the convenience euthanasia take care of him and it was initially okay but now he has dilemma become annoying. It is the same thing with the different Veterinarians commented spontaneously about this breeds. I think that if we do not have consideration about topic without direct questioning living beings, it is easier to discard them. I think it is the Some veterinarians provided information on the correlation circle of influence of our times. Did we have something between the various motivations to adopt a companion animal to do with it? Yes, we did!” and the type of perceived owner-animal bond. Some motivations were more likely to result in a request for convenience Some veterinarians saw convenience euthanasia as a humane euthanasia. The owners did not reflect sufficiently on the way to help the situation of animal overabundance created in implications involved prior to the adoption of the animal, part by the consumption habits of society. which seemed to prevent strong bonding between the owner One veterinarian identified the general public’s ignorance of and animal. Examples included situations such as adopting the convenience euthanasia to explain the origin of the dilemma: animal because it is pretty, on the spur of the moment, or due “The first week of work here was “moving week” and I to pressure from children. These situations failed to create the performed 21 procedures of convenience euthanasia. I active involvement necessary from the owner concerning his did an average of three daily. At the end of the week 1 was obligation toward the animal. asking myself why was I doing this job? I can understand Some veterinarians believed that the legal social status of a if you have to move, that it can be difficult to find a place companion animal in society was at the core of the convenience accepting companion animals, you cannot be picky about euthanasia dilemma. The lack of consideration of the animal’s the choice of apartment. But the client does not know that interests or needs within Quebec’s legislation did not encourage it is your fifth case of the day. They think it is always easy companion animal owners to view their animal differently from for you, that you just have to administer the injection, put the status of property. This situation, therefore, also contributed the animal in a bag and bring him to the freezer. Yes, we to minimization of the animal’s needs and interests. try to create a barrier and detach ourselves from the situ- The overabundance of companion animals in Quebec is ation because it is not our animal. But, the dog is there, illustrated by the high occupancy rate of animal shelters. Some he is watching you, he wags his tail, he looks nice and you veterinarians referred to this situation in order to explain the do not want to do it. He could die old after a nice life, but origin of the dilemma. They saw a clear link between society’s you have to kill him because of his owner’s decision, he is consumption habits and the low value bestowed on animals. not attached to him anymore, he is tired of his animal, he The animal’s individual value was low because the number of is not cute anymore.” animals waiting for a new home was always more important Ignorance may be a loophole in the general public’s education than the number of owners searching for a new companion with regard to responsibilities associated with the care of an animal. This overabundance of companion animals made them animal. However, it is difficult for veterinarians to precisely and easily replaceable objects. Veterinarians expressed themselves on uniformly define this concept of responsibility. the overabundance effect and the loss in value within society: “There are two types of clients. The first type loves ani- Theme 3: Veterinary involvement in the dilemma mals, they care for them. The second is an animal con- Veterinarians commented spontaneously about this topic with- sumer. We are a consumption society and this is the out direct questioning. A few veterinarians discussed their own problem. People are consumers of animals as if they were involvement in the dilemma. Some veterinarians refused to simple objects. I think it is within society and it will not believe that they share responsibility in the dilemma of con- change soon, it is too deeply rooted within us. It is too venience euthanasia. They even doubted the existence of the large. Convenience euthanasia is normal because animals dilemma in their professional activities. For them, the problem are seen as objects.” came from veterinarians who refused to perform convenience

258 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY euthanasia. They thought that those veterinarians were against activity and rarely are veterinarians willing to refuse client the practice of convenience euthanasia because they were demands. Some saw convenience euthanasia as a conflict of uncomfortable with the general concept of death. In their opin- interest and others saw it as a service. ion, the discomfort originated from a lack of emotional manage- Our study results also fit with the pediatrician (4) and biocen- ment because they were unable to create distance between the tric models (1). Some veterinarians were systematically refusing professional situation and their own emotions. to perform convenience euthanasia. They were medical profes-

One veterinarian estimated that the profitability pressure of sionals acting as advocates to protect their patients. ARTICLE veterinary facilities amplified the dilemma. This veterinarian Convenience euthanasia is a sensitive topic within the profes- expressed himself on the subject by explaining that leaders of sion and is recognized as a stress factor for practitioners (2,5). veterinary businesses were not able to imagine the situation Paradoxically, veterinarians interviewed, although not specifically differently and continued to profit from those cases. They were questioned, did not talk about themselves as active participants then automatically disengaging. in convenience euthanasia decisions. However, they identified the context of companion animal adoption as a major contribu- “By the same token, what can I do? It is on this that we tor to the dilemma. The first theme of this article indicated need to work. What are the alternatives that I can offer that the owner-animal bond was a major factor in the decision and how can I do this? Is it possible to work differently? process of convenience euthanasia. According to some partici- Am I sure that there are other ways to explore, are there pants in this study, the motivation to adopt a companion ani- other solutions to try? And why am I asking myself those mal was very important for the identification of the dilemma’s questions? Is it because nobody else is trying to find a solu- origin. This motivation had a direct impact on the importance tion? I think that the profitability pressure has taken over attributed to the animal by the owner. A weak bond led to an within our facilities. And maybe it is up to institutions to anthropocentric definition of the animal and the recognition work on the topic, because short-term evaluation is not of the animal’s interests was then poor. For some veterinarians, profitable for veterinary businesses. Long-term evaluation convenience euthanasia was considered a humane method to will be profitable for society.” stabilize the situation of companion animal overabundance. Another veterinarian explained that it is easier for veterinar- Finally, the results of this study cannot be extrapolated ians to accept all requests of convenience euthanasia rather than to represent the point of view of veterinarians in Quebec on defend the animal’s interests. Use of convenience euthanasia convenience euthanasia because the sample size was small and to get rid of unwanted companion animals is a widespread there were limitations related to the qualitative research design. practice. This respondent believed that veterinarians performed The purpose of qualitative research is to collect the widest range euthanasia because they were now used to doing the procedure. of opinions possible; therefore, data cannot be extrapolated The habit of performing convenience euthanasia trivialized the to quantitatively represent the entire veterinary community. procedure and did not encourage veterinarians to reflect on the Research has not been done on the differences in veterinary moral aspect of this act. practice from country to country or even from province to province in Canada. The goal of this research was to qualitatively Discussion describe the situation of convenience euthanasia and represents Evaluation of veterinarians’ perception of animals illustrated the perspectives of 14 veterinarians in Quebec. the discrepancy between veterinarians’ moral value attributed to The goal of this study was to describe veterinarians’ con- their own pets and the perceived strength of the owner-animal ceptualization and experience of convenience euthanasia. The bond of their clients. In cases of convenience euthanasia, vet- analysis of responses brought to light many components of the erinarians’ responses predominantly reflected their perception dilemma and led to a better understanding of this issue. The concerning the lack of importance attributed to the animal’s veterinarians interviewed decide about convenience euthanasia moral value within society. The moral value attributed in rela- based mainly on their analysis of the owner-animal bond. As tion to the owner-animal bond excluded the animal’s interests most veterinarians in this study view animals in an anthropo- from the debate of convenience euthanasia. It is therefore pos- centric way, the animal’s interests and needs are not necessarily sible to understand why most of the veterinarians interviewed taken into consideration. Some veterinarians believed that the would perform convenience euthanasia. Their view on the origin of the dilemma came from social weakness (i.e., the subject was influenced by their perception of the owner-animal owner’s inability to take responsibility). Further analysis of this bond during the appointment. dilemma is currently being done. Consequences resulting from Morgan and McDonald (1) explored different visions of the decision about convenience euthanasia on each stakeholder the animal’s value in dilemmas within the field of veterinary will be assessed. medicine. They described and classified those visions in either This study provides a description of the issue of convenience an anthropocentric or a biocentric model. Our results fit this euthanasia and is the first to highlight the absence of animal wel- model. fare discussion by all participants in this study in the context of Veterinarians perceiving animals in an anthropocentric model convenience euthanasia. However, veterinarians were not directly corresponded to Rollin’s garage mechanic model (4). They questioned about animal welfare. Convenience euthanasia is a were acting as service providers and were not getting personally sensitive topic, but veterinarians did not describe themselves as involved in the dilemma. Veterinary medicine is a profitable major actors in the dilemma. These results did not assess the

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prevalence of responses reported within the entire population of 6. Yeates JW, Main DC. Veterinary opinions on refusing euthanasia: veterinarians in Quebec. A second study involving a quantitative Justifications and philosophical frameworks. Vet Rec 2011;168:263. 7. Kay WJ. Euthanasia of the Companion Animal: The Impact on Pet evaluation of the concepts reported in this article has already Owners, Veterinarians, and Society. Philadelphia, Pennsylvania: Charles been undertaken. Press, 1988. 8. Leary S, Underwood W, Anthony R, et al. AVMA Guidelines for the Euthanasia of Animals: 2013 Edition. Available from https://www.avma. Acknowledgments org/KB/Policies/Documents/euthanasia.pdf Last accessed January 13, We thank the veterinarians interviewed for sharing their time 2017. 9. Singer P. La libération animale. Paris, France: Grasset, 1993. and experiences. We also thank Mr. Philippe Aubert Côté for 10. Regan T. The Case for Animal Rights. Berkeley, California: University his time and expertise during the research project. This research of California Press, 2004. ARTICLE was funded by the Fonds en santé des animaux de compagnie 11. Groupe de recherche interdisciplinaire sur les méthodes qualitatives (Québec), & Poupart, J. La recherche qualitative: enjeux épisté- de l’Université de Montréal and the Association des Médecins mologiques et méthodologiques. Montréal, G. Morin, 1997. Vétérinaires du Québec (animaux de compagnie). CVJ 12. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health References 2015;42:533–544. . 1 Morgan CA, McDonald M. Ethical dilemmas in veterinary medicine. 13. Dépelteau F, ed. La démarche d’une recherche en sciences humaines. Vet Clin North Am Small Animal Pract 2007;37:165–79. Les presses de l’Université Laval et De Boeck Université, Québec, 2009. 2. Tannenbaum J. Veterinary Ethics: Animal Welfare, Client Relations, 14. Guest GB, Bunce A, Johnson L. How many interviews are enough? Competition and Collegiality. 2nd ed. St. Louis, Missouri: Mosby, 1995. An experiment with data saturation and variability. Field Methods 3. Morgan CA. Stepping up to the Plate: Animal Welfare, Veterinarians, 2006;18:59–82. and Ethical Conflicts. [PhD Thesis]. Vancouver, British Columbia, 15. Van der Maren J-M. Méthodes de recherche pour l’éducation. Montréal, University of British Colombia, 2009. Québec: Presses de l’Université de Montréal et de Boeck, 1996. 4. Rollin BE. Animal Rights and Human Morality. 3rd ed. Amherst, 16. Miles MB, Huberman AM. Analyse des données qualitatives. Louvain- New York: Prometheus Books, 2006. la-Neuve, Belgium: De Boeck Supérieur, 2003. 5. Morris P. Blue Juice: Euthanasia in Veterinary Medicine. Philadelphia, 17. Paillé P. De l’analyse qualitative en général et de l’analyse thématique Pennsylvania: Temple University Press, 2012. en particulier. Recherches qualitatives 1996;15:179–194.

260 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY Case Report Rapport de cas

Dexmedetomidine to control signs associated with lisdexamfetamine dimesylate toxidrome in a cat

Christopher L. Norkus, Iain Keir, Charlotte Means

Abstract — A 5-month-old intact female domestic shorthaired cat had mydriasis, agitation, and increased locomotion after ingestion of lisdexamfetamine, 10.3 mg/kg body weight (BW). Despite treatment with IV fluids, IV acepromazine, oral cyproheptadine and intravenous lipid emulsion the patient’s clinical signs worsened. Dexmedetomidine administered at 2 mg/kg BW and continued at 0.5 mg/kg BW per hour rapidly controlled the patient’s signs. An episode of vomiting and hematuria developed. Follow-up 5 days after discharge revealed that the cat appeared normal.

Résumé — Dexmédétomidine pour contrôler les signes associés à la toxidrome à la lisdexamfétamine dimesylate chez une chatte. Une chatte domestique intacte âgée de 5 mois présentait de la mydriase, de l’agitation et une locomotion accrue après avoir ingéré de la lisdexamfétamine, 10,3 mg/kg poids corporel (PC). Malgré le traitement à l’aide de solutions intraveineuses, d’acépromazine intraveineuse, de cyproheptadine orale et d’émulsion de lipides intraveineux, les signes cliniques de la patiente s’étaient aggravés. La dexmédétomidine administrée à 2 mg/kg PC et maintenue à 0,5 mg/kg PC l’heure a rapidement contrôlé les symptômes de la patiente. Un épisode de vomissements et d’hématurie s’est développé. Un suivi 5 jours après le congé a révélé que la chatte semblait normale. (Traduit par Isabelle Vallières) Can Vet J 2017;58:261–264

mphetamine, dextroamphetamine, and methylphenidate activity. Lisdexamfetamine was developed to provide extended A are first-line therapies in treating attention-deficit/hyper- duration of action with lower potential for abuse and toxicity. activity disorder (ADHD) in humans and are a potential source Lisdexamfetamine toxidrome and treatment remain to be char- of toxicity for companion animals. Reports of toxicosis in dogs acterized in the veterinary literature. We report the successful and cats include central nervous system (CNS), cardiovascular, treatment of a cat with lisdexamfetamine toxidrome using gastrointestinal, and hematologic changes including agitation, dexmedetomidine in conjunction with traditional therapies for seizures, hyperactivity, hyperthermia, tachycardia, hyperten- amphetamine toxicosis and intravenous lipid emulsion. sion, mydriasis, aggression, vomiting, metarubricytosis, and death (1–5). Case description Lisdexamfetamine dimesylate (Vyvanse Shire US; Wayne, A 5-month-old intact female domestic shorthair cat weighing Pennsylvania, USA) is approved by the United States Food & 2.9 kg was presented following observed ingestion of a 30-mg Drug Administration for ADHD and binge eating disorder in capsule [10.3 mg/kg body weight (BW)] of lisdexamfetamine adults. In humans, lisdexamfetamine is an inactive prodrug dimesylate (Vyvanse Shire) 1 h earlier. On triage the patient that converts to l-lysine, an essential amino acid, and active was alert with normal vital signs. The owner reported no past dextroamphetamine, which is responsible for lisdexamfetamine’s medical history. Physical examination findings included patient agitation, hyperactivity, and bilateral mydriasis. Muscle tremors Allegheny Veterinary Emergency Trauma & Specialty, were not observed. Venous blood gas, electrolyte panel, and 4224 Northern Pike, Monroeville, Pennsylvania, 15146, lactate level were unremarkable. USA (Norkus, Keir); ASPCA Animal Poison Control Center, Ninety minutes following ingestion, acepromazine (VETone, 1717 S Philo Road, Suite 36 Urbana, Illinois 61802, USA Boise, Idaho, USA), 0.03 mg/kg BW, IM, was administered (Means). to facilitate catheter placement. Intravenous fluids were initi- Address all correspondence to Dr. Christopher Norkus; e-mail: ated with lactated ringer’s solution (Lactated Ringers, Abbott [email protected] Laboratories, Abbott Park, Illinois, USA) bolus, 25 mL/kg BW, Use of this article is limited to a single copy for personal study. then 110 mL/kg BW per day with 20 mEq/L KCl (Hospira, Anyone interested in obtaining reprints should contact the Lake Forest, Illinois, USA). Activated charcoal was not admin- CVMA office ([email protected]) for additional istered due to the duration of time that had elapsed since copies or permission to use this material elsewhere. ingestion and the presence of neurological signs (6). Continued

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treatment included acepromazine (Phoenix, Clipper Distributing and the patient’s plasma remained lipemic. A repeat urinalysis Company, St Joseph, Missouri, USA), 0.03 mg/kg BW, IV, q6h, revealed no new findings aside from the presence of a large cyproheptadine (Merck & Co, Kenilworth, New Jersey, USA), number of red blood cells. A 20 mL/kg BW bolus of LRS was 2 mg PO, q8h, and hospitalization in a quiet, dark environment, administered resulting in a SAP of 110 mmHg. based upon recommendations of the ASPCA Animal Poison Dexmedetomidine was discontinued 27 h after ingestion Control Center, Urbana, Illinois, USA. as the patient remained clinically improved and the cat was Eight hours after ingestion the patient was agitated, aggres- discharged with oral cyproheptadine, 2 mg PO, q8h for con- sive, and hyperactive. Acepromazine, 0.02 mg/kg BW, IV, tinued serotonin antagonism. Follow-up with the owner 48 h was administered twice to facilitate patient evaluation and after discharge indicated the patient had mild signs of intoxica- partially controlled clinical signs. Twelve hours after exposure tion for approximately 12 h following discharge but had since hypertension was noted via Doppler with a systolic blood returned to normal. Repeat blood chemistry 5 d following RAPPORTCAS DE pressure (SAP) of 250 mmHg [adult reference interval (RI): discharge revealed alanine aminotransferase of 207 IU/L (RI: 12 100 to 160 mmHg]. Acepromazine was repeated to a total of to 115 IU/L). 0.15 mg/kg BW, IV to control the hypertensive crisis, resulting in a SAP of 156 mmHg. Despite the increased aceproma- Discussion zine dosage the patient’s agitation and increased locomotion This case report is the first description of lisdexamfetamine remained only partially controlled. intoxication in the cat. Successful management included Seventeen hours after ingestion an electrocardiogram revealed the use of dexmedetomidine along with standard therapies normal sinus rhythm. Complete blood cell counts were within for amphetamine toxicosis and intravenous lipid emulsion. the adult reference intervals. Blood chemistry revealed an ele- Lisdexamfetamine intoxication resulted in agitation, hyper- vated alkaline phosphatase at 93 IU/L (RI: 12 to 59 IU/L), ala- reactivity, and self-mutilation, which failed to respond to nine transaminase at 284 IU/L (RI: 27 to 158 IU/L), aspartate previously published therapies (7). Dextroamphetamine is a transaminase at 912 IU/L (RI: 16 to 67 IU/L), and hypernatre- sympathomimetic that results in CNS excitation by inhibit- mia of 158 mmol/L (RI: 142 to 155 mmol/L), hyperphosphate- ing reuptake of norepinephrine and dopamine in presynaptic mia at 7.1 mmol/L (RI: 2.9 to 6.3 mmol/L), hypoproteinemia neurons while promoting their release extraneuronally (8,9). at 60 g/L (RI: 63 to 88 g/L), and hypoglobulinemia at 25 g/L; In large doses dextroamphetamine also results in postsynaptic (RI: 30 to 59 g/L). The hypoproteinemia, elevated alkaline 5-HT elevation that results in serotonin syndrome and CNS phosphatase, and hyperphosphatemia were consistent with the excitability (9). Treatment for amphetamine toxidrome is similar patient’s age. A urinalysis obtained via cystocentesis revealed in humans and veterinary medicine including discontinuation a specific gravity of 1.015, pH 8, and an inactive sediment. of the drug and supportive therapy; no specific antidote exists. Due to worsening agitation, aggressiveness, and hyperactiv- In healthy adult humans the time to reach maximum plasma

ity, intravenous lipid emulsion (ILE) therapy (Intralipid Fat drug concentration (TMax) following ingestion of lisdexamphet- Emulsion 20%, Fresenius Kabi, Upsala, Sweden) was initiated amine is 1 h, with a rapid elimination half-life (T1/2) of 0.47 h at 1.5 mL/kg BW, IV bolus followed by 0.25 mL/kg BW/min (10). These data support our decision to not induce emesis or continuous rate infusion (CRI) for 60 min until the cat’s plasma use activate charcoal at the time of the cat’s presentation. The was noted to be lipemic. plasma half-life for dextroamphetamine, however, is 10.39 h Eighteen hours after ingestion the cat’s condition appeared in humans, following first-order kinetics, and may vary with

to be worsening with increasing agitation, hyperactivity, and urine pH (10). The oral LD50 of dextroamphetamine in rats episodes of open mouth breathing. Self-mutilation behavior is 32 mg/kg BW (11). The LD50 and plasma half-life for lis- was also observed consisting of repeated scratching of the dexamfetamine have not been established in cats. Based upon neck and face region resulting in bleeding. Acepromazine unpublished observation of other cats with lisdexamphetamine was discontinued due to incomplete effectiveness and the ingestion and the time course for complete resolution of this perceived need for repeated and escalating dosages that could patient’s signs following discharge, lisdexamphetamine toxi- have resulted in adverse effects. Dexmedetomidine (Zoetis, drome may last up to 40 h in cats (12). Kalamazoo, Michigan, USA), 2 mg/kg BW, IV, was adminis- In a series of 3 independent rat toxicology studies, all rats tered and continued at 0.5 mg/kg BW per hour. Following the administered . 60 mg/kg BW of lisdexamfetamine exhibited dexmedetomdine bolus the patient’s hyperactivity and distress increased locomotion lasting beyond 24 h. At higher doses rats immediately resolved and the cat began to eat. A single episode exhibited self-mutilation leading to death (13). In rats, repeated of vomiting was noted and was treated with maropitant (Zoetis) administration of dextroamphetamine can induce hepatic and 1 mg/kg BW, SQ. A normal heart rate and SAP of 170 mmHg renal changes (14). It remains unclear if the patient’s hepatic were documented. enzyme elevation was due to pre-existing causes or lisdexamfet- Twenty-two hours after ingestion the patient’s clinical signs amine induced hepatocellular injury. The cause of the patient’s remained fully controlled with dexmedetomdine but hematuria pigmenturia also remains unclear. Although rhabdomyolysis and was observed. A vaginal examination was unremarkable and SAP secondary myoglobinuria would have been consistent with the was 70 mmHg. A focused abdominal ultrasound confirmed no patient’s clinical signs, hematuria was identified on the patient’s abdominal hemorrhage. A packed cell volume (PCV) was 53% urinalysis with sediment. The cause of the hematuria may be (RI: 29 to 48%), total protein was 103 g/L (RI: 52 to 88 g/L), iatrogenic following cystocentesis or secondary to ILE-induced

262 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY hemolysis. However, the patient’s packed cell volume at the time We cannot exclude a potential role of cyproheptadine in the (53%) does not support the diagnosis of hemolysis. Ultimately management of this patient. Cyproheptadine is a histamine-1 we cannot rule out an effect of lisdexamfetamine. Approximately receptor antagonist with nonspecific 5-HT1A and 5-HT2A 96% of dextroamphetamine is excreted by the urine after a antagonistic properties that has been suggested to control sero- single oral dose, with only 0.3% present in the feces (8). To tonin syndrome (22,23). It is worth noting, however, that the encourage renal diuresis intravenous fluid administration was cat in this case received several doses of cyproheptadine and had REPORT CASE continued throughout the patient’s hospital stay at 110 mL/kg poorly controlled and worsening clinical signs until dexmedeto- BW per day. midine was initiated. The American Society for the Prevention of Cruelty to Injectable lipid emulsions consist of soy oil, glycerol, and Animals Animal Poison Control Center (APCC) electronic egg phospholipids and are a major component for parenteral database was searched for all cases of cats with known or sus- nutrition. One theory for the mechanism is that ILE expands pected exposure to lisdexamfetamine between January 2008 and the intravascular lipid phase which acts to sequester lipophilic February 2016. Information obtained included signalment, esti- toxins within it, thus reducing the effect site concentration mated dose and time of ingestion, onset, severity and duration and toxicity until the compound is metabolized and excreted of clinical signs, and treatments administrated. Cases chosen (24). Other theories for ILE’s mechanism of action include for inclusion were limited to single agent ingestions, and cases providing myocytes with energy substrates thereby augment- assessed as high or medium suspicion of intoxication. A total ing cardiac performance, restoring myocardial function by of 192 cases met the criteria for inclusion, and the dose range increasing intracellular calcium concentration, and by increas- in the cases (when known) ranged from 1.67 to 77 mg/kg BW. ing the overall fatty acid pool thus overcoming inhibition of The most common clinical sign reported was mydriasis (60% mitochondrial fatty acid metabolism (25). A drug is deemed of cases); 38.5% of cases reported tachycardia, while hyperten- lipophilic if its octanol/water partition coefficient (log P) value sion was only reported 5.2% of the time, but not every case is . 1.0 (26). Log P is the partition coefficient of a drug in a had blood pressure monitored. Most cases report 1 or more solvent and theorizes how quickly a drug will dissolve into the stimulatory central nervous system signs including agitation, tissues. Dextroamphetamine, which is responsible for lisdexam- hyperactivity, disorientation, vocalizing, pacing, ataxia, circling, fetamine’s activity, has a log P of 1.76 (27). Intravenous lipid head bobbing, staring, hyperesthesia, as well as various behav- emulsion has been used in humans to treat amphetamine and ior changes. Hyperthermia was reported in 29.6% of cases. methamphetamine overdoses with both drugs having similar log Tachypnea, panting, and/or mouth breathing were reported P-values similar to lisdexamfetamine, 1.76 and 2.07, respectively in 44% of cases. Hypersalivation and/or vomiting occurred in (28,29). Injectable lipid emulsion therapy was administered 29% of cases (12). with speculation that it may bind free lisdexamfetamine in the Dexmedetomidine is an alpha-2 adrenergic agonist that pos- lipid phase, preventing CNS binding, and thus improving the sesses anxiolytic, sedative, analgesic, and muscle relaxant quali- patient’s clinical signs. ties. Dexmedetomidine provides effective sedation with minimal Potential side effects of lipid therapy include hypersensitiv- respiratory depression or the need for endotracheal intubation ity reactions, phlebitis, fat embolism, fat overload syndrome, and, unlike benzodiazepines, does not commonly result in pancreatitis, worsening of acute respiratory distress syndrome, paradoxical reactions (15,16). Dexmedetomidine may effectively hemolysis, alteration to laboratory values, and coagulopathy treat amphetamine toxidrome because presynaptic activation of (25). Because plasma concentrations were not measured in alpha-2 adrenoceptors inhibits the release of norepinephrine and this patient, it remains unclear what effect the ILE had on the stimulation of postsynaptic alpha-2 adrenoreceptors can decrease progression of this cat’s toxidrome and ILE’s contribution to the hyperlocomotion, hypertension, and tachycardia in patients with resolution of this patient’s clinical signs remains speculative. It serotonin syndrome (17). Literature on rodents and humans is worth noting that ILE could also potentially interfere with suggests that dexmedetomidine may be more effective than other other medications administered to this patient including the agents such as benzodiazepines and propofol in controlling signs dexmedetomidine and cyproheptadine. associated with serotonin syndrome and should be considered as To the authors’ knowledge this is the first report of lisdexam- a treatment option (18–20). Dexmedetomidine has been used phetamine toxidrome in the cat. Lisdexamphetamine toxidrome successfully to specifically treat lisdexamfetamine overdose and appears to be similar to toxicosis from other amphetamines in serotonin syndrome in a child (21). Bradycardia and hypoten- the feline species. This case report supports the use of dexme- sion are possible complications, but may be ameliorated by detomidine as a novel treatment modality in conjunction with decreasing infusion rates and augmenting intravascular volume standard therapies for amphetamine toxicosis in the cat. The as described in this case. The cat herein showed immediate potential benefit of intravenous lipid emulsion in this case improvement in its clinical signs following dexmedetomidine remains speculative. Evaluation of hepatic enzymes in cats with administration. Although we cannot rule out spontaneous lisdexamphetamine toxidrome is recommended. CVJ resolution of the toxidrome at 18 h after ingestion, this would be inconsistent with the reported time course of the drug in References humans (based upon expected plasma concentrations at not . 1 Gustafson BW. Methylphenidate toxicosis in a cat. J Am Vet Med Assoc 1996;208:1052–1053. yet 2 plasma half-lives) and the history that the cat continued 2. Bischoff K, Beier E, 3rd, Edwards WC. Methamphetamine poisoning to show mild clinical signs up to 40 h following ingestion (10). in three Oklahoma dogs. Vet Hum Toxicol 1998;40:19–20.

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. 3 Wilcox A, Russell KE. Hematologic changes associated with Adderall 16. Mancuso CE, Tanzi MG, Gabay M. Paradoxical reactions to benzodiaz- toxicity in a dog. Vet Clin Pathol 2008;37:184–189. epines: Literature review and treatment options. Pharmacother 2004;24: 4. Genovese DW, Gwaltney-Brant SM, Slater MR. Methylphenidate 1177–1185. toxicosis in dogs: 128 cases (2001–2008). J Am Vet Med Assoc 2010; 17. Gertler R, Brown HC, Mitchell DH, Silvius EN. Dexmedetomidine: 237:1438–1443. A novel sedative-analgesia agent. Proc Bayl Univ Med Cent 2001;14: 5. Pei Z, Zhang X. Methamphetamine intoxication in a dog: Case report. 13–21. BMC Vet Res 2014;24:139. 18. Spiller HA, Hays HL, Aleguas A, Jr. Overdose of drugs for attention- 6. American Academy of Clinical Toxicology and European Association of deficit hyperactivity disorder: Clinical presentation, mechanisms of Poisons Centers and Clinical Toxicologist. Position Paper: Single-Dose toxicity, and management. CNS Drugs 2013;27:531–543. Activated Charcoal. Clinical Toxicology 2005;43:61–87. 19. Rushton WF, Charlton NP. Dexmedetomidine in the treatment of 7. Stern LA, Schell M. Management of attention-deficit disorder and serotonin syndrome. Ann Pharmacother 2014;48:1651–1654. attention-deficit/hyperactivity disorder drug intoxication in dogs and 20. Kawano T, Takahashi T, Kaminaga S, et al. A comparison of midazolam cats. Vet Clin North Am Small Anim Pract 2012;42:279–287. and dexmedetomidine for the recovery of serotonin syndrome in rats. 8. Vyvanse (Lisdexamfetamine dimesylate) [package insert]. Wayne, J Anesth 2015;29:631–634.

RAPPORTCAS DE Pennsylvania: Shire Pharmaceuticals; 2008. 21. Akingbola OA, Singh D. Dexmedetomidine to treat lisdexamfetamine 9. Kuczenski R, Segal DS, Cho AK, et al. Hippocampus norepinephrine, overdose and serotonin toxidrome in a 6-year-old girl. Am J Crit Care caudate dopamine and serotonin, and behavioral responses to the ste- 2012;21:456–459. rioisomers of amphetamine and methamphetamine. J Neurosci 1995; 22. Graudins A, Stearman A, Chan B. Treatment of the serotonin syndrome 15:1308–1317. with cyprohepatadine. J Emerg Med 1998;16:615. 10. Krishnan SM, Pennick M, Stark JG. Metabolism, distribution, and 23. Sporer KA. The serotonin syndrome. Implicated drugs, pathophysiology, elimination of lisdexamfetamine dimesylate: Open-label, single-center , and management. Drug Saf 1995;13:94–104. phase 1 study in healthy volunteers. Clin Drug Investig 2008;28: 24. Cave G, Harlvey M. Graudins A. Intravenous lipid emulsion as an 745–755. antidote: A summary of published human experience. Emerg Med 11. Sigma-Aldrich I. Material safety data sheet: d-amphetamine sulfate. Australas 2011;23:123–141. Available from: http://www.sigmaaldrich.com/catalog/search/Product 25. Silverstein D, Hopper K. Small Animal Critical Care Medicine. 2nd ed. Detail/SIGMA/A5880 Last accessed January 3, 2017. St. Louis, Missouri: Elsevier Saunders, 2015. 12. AnTox Database. ASPCA Animal Poison Control Center 2016, Urbana, 26. Fernandez A, Lee J, Rahilly L, Hovda L, Brutlag AG, Engebretsen K. Illinois, USA. Available from: http://aspcapro.org/animal-poison- The use of intravenous lipid emulsion as an antidote in veterinary control-center Last accessed January 17, 2017. toxicology. J Vet Emerg Crit Care 2011;21:309–321. 13. Krishnan S, Montcrief S. Toxicity profile of lisdexamfetamine dimesyl- 27. Hansch C, Leo A, Hoekman D. Exploring QSAR — Hydrophobic, ate in three independent rat toxicology studies. Basic Clin Pharmacol Electronic, and Steric Constants. Washington, DC: American Chemical Toxicol 2007;101:231–240. Society, 1995:61. 14. Carvalho F, Fernandes E, Remiao F, de Lourdes Bastos M. Effect of 28. Cao D, Heard K, Foran M, Koyfman A. Intravenous lipid emulsion d-amphetamine repeated administration on rat antioxidant defenses. in the emergency department: A systematic review of recent literature. Arch Toxicol 1999;73:83–89. J Emerg Med 2015;48:387–397. 15. Simon BT, Scallan EM, Siracusa C, Henderson A, Sleeper MM, 29. Tse J, Ferguson K, Whitlow KS, Erickson K. The use of intravenous Larenza Menzies MP. Effects of acepromazine or methadone on mid- lipid emulsion therapy in acute methamphetamine toxicity. Am J Emerg azolam-induced behavioral reactions in dogs. Can Vet J 2014;55: Med 2016;34:1732 e3–4. 875–885.

264 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY Case Report Rapport de cas

Kidney injury in a dog following bee sting-associated anaphylaxis

Christopher Corrie, Gareth James Buckley, Carsten Bandt, Michael Schaer

Abstract — This report describes a case of honeybee envenomation in a dog that developed anaphylaxis after being stung by approximately 10 bees. The dog subsequently developed acute kidney injury. The dog had a previous mild increase in blood urea nitrogen with normal creatinine, possibly indicating an insidious chronic renal degenerative process that went into acute decompensation at the time of bee envenomation.

Résumé — Lésion rénale chez un chien après l’anaphylaxie associée à une piqûre d’abeille. Ce rapport décrit un cas d’envenimement d’un chien qui a été piqué par environ 10 abeilles et a développé l’anaphylaxie puis une lésion rénale aiguë. Le chien avait eu une légère hausse antérieure de l’azote uréique du sang avec une créatinine normale, ce qui indique éventuellement un processus dégénératif rénal chronique insidieux qui s’est développé en une décompensation aiguë au moment de l’envenimement par les abeilles. (Traduit par Isabelle Vallières) Can Vet J 2017;58:265–269

evere systemic allergic reactions in dogs living in North and norepinephrine (5), with melittin being the main compo- S America most commonly occur because of an insect bite nent of venom both by amount and lethality. Melittin, acting or sting, and the most clinically important encounters origi- synergistically with phospholipase A2, disrupts cell membranes nate from insects belonging to the order Hymenoptera (1,2). of certain mammals and causes lysis of erythrocytes, leukocytes, The 3 groups of Hymenoptera most frequently responsible for platelets, myocytes, and vascular endothelium (6). This in turn physical symptoms relating to allergic reactions seen in veteri- releases myoglobin and hemoglobin, which have been linked to nary hospitals are: Apidae (bees), Vespidae (hornets, wasps, and acute tubular necrosis and acute kidney injury (AKI) in humans yellow jackets), and Formicidae (fire ants) (3). Although honey- and other species, including dogs (7–9). Melittin has also been bees are comparably more docile than most of these venomous associated with acute myocardial ischemia, producing arrhyth- hymenopterans, they are very protective of their hives and they mias (6,10). Peptide 401 causes mast cells to release histamine will attack humans or animals that pose a threat to their habitat. and vasoactive amines causing vasodilation (1). Hyaluronidase The venom in the sting can cause pathology ranging from local causes breakdown of connective tissue and promotes further benign lesions to severe life-threatening systemic reactions. uptake and spread of venom (6). Honeybees are only able to sting once, as their barbed stinger Reactions to insect envenomation fall into 5 main categories: catches in the victim’s skin, pulling the stinging apparatus from local pain and swelling, larger regional reaction, anaphylactic the bee’s body causing the bee to die. The venom sac continues reaction, serum sickness (delayed-type hypersensitivity) occur- to contract outside the bee’s body and 100% of the venom is ring 3 d to 2 wk after envenomation, and a rare delayed toxic delivered within 60 s (4). reaction in humans seen within 24 h after severe envenom- The main components of bee venom are: melittin, peptide ation characterized by hemolysis, coagulopathy, hepatopathy,

401 (mast cell degranulating peptide), phospholipase A2, hyal- thrombocytopenia, and disseminated intravascular coagulation uronidase, histamine, dopamine, acid phosphatase, apamine, (DIC) (1,11). Anaphylaxis, a Type I (immediate) hypersensitivity mediated by IgE, is the most serious complication in dogs. Anaphylactoid reactions resemble anaphylaxis but are indepen- University of Florida College of Veterinary Medicine — dent of IgE and, although compounds have been identified that Small Animal Clinical Sciences, Gainesville, Florida, USA act directly on cell membranes of mast cells, the exact mecha- (Buckley, Corrie, Schaer); Canada West Veterinary Specialists nism for these reactions remains unclear (12). Both anaphylactic — Emergency & Critical Care, Vancouver, British Columbia and anaphylactoid reactions are similar in their appearance and (Bandt). treatment, and consequently the terms are often used inter- Address all correspondence to Dr. Gareth Buckley; e-mail: changeably (12). The combined effects of severe envenomation [email protected] and anaphylaxis include intravascular hemolysis, rhabdomy- Use of this article is limited to a single copy for personal study. olysis, hepatopathy, cardiac damage, AKI, immune-mediated Anyone interested in obtaining reprints should contact the hemolytic anemia (IMHA), immune-mediated thrombocyto- CVMA office ([email protected]) for additional penia (IMTP), and DIC (1,10,11,13–15). Acute lung injury/ copies or permission to use this material elsewhere. acute respiratory distress syndrome (ALI/ARDS) as defined by

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acute onset of bilateral pulmonary infiltrates without evidence Table 1. Blood gas values, packed cell volume (PCV), and total of left atrial hypertension and subsequent hypoxemia has been solids (TS) in a dog with bee sting envenomation reported in dogs and substantiated using advanced imaging On 7 hours 40 hours Reference and pulmonary function tests (16). This paper describes a dog presentation later later range envenomated by honeybees resulting in acute kidney injury. pH 7.28 7.38 7.44 7.33 to 7.44 pCO2 32.2 27.8 26.4 35 to 40 mmHg pO2 68.1 70.9 91.6 32 to 62 mmHg Case description Glucose 4.12 5.33 5.95 4.78 to 6.1 mmol/L A 9-year-old intact female mixed breed dog weighing 10.8 kg Lactate 3.0 0.8 0.7 0.4 to 1.5 mmol/L was presented to the referring veterinarian after being found BUN 19.6 18.5 16.1 3.57 to 10.7 mmol/L Creatinine 185.64 176 140.8 70.4 to 132 mmol/L unresponsive in the owner’s truck with at least 10 bees, some HCO3 15.5 16.7 18.3 18 to 27 mmol/L of which were dead. Honeybees used for crop pollination had TCO2 16.5 17.5 19.1 19 to 28 mmol/L RAPPORTCAS DE been released within the previous hour near the truck which was PCV 51 37% to 55% TS 64 51 to 78 g/L parked under a tree with the windows down. Ten months before this incident, routine blood test results from the dog showed BUN — blood urea nitrogen. a mild increase in blood urea nitrogen (BUN) with a normal creatinine [BUN 19.2 mmol/L, reference range (RR): 3.2 to after receiving the fluids the systolic blood pressure increased 11.0 mmol/L; creatinine 114.4 mmol/L, RR: 44 to 132 mmol/L] to 156 mmHg and the mentation improved, as evidenced and mild anemia (hematocrit, HCT, 0.34, RR: 0.38 to 0.56) by the dog being able to lift its head and respond to physical without appreciable dehydration or clinical signs of kidney touch and sound. The dog was then moved to an oxygen cage

disease. No further testing was done at that time so, while a with a fraction of inspired oxygen (FiO2) of 0.4 and placed mild chronic kidney disease (CKD) (IRIS Stage 1) at the time on LRS at 35 mL/h, which was maintained throughout the of the envenomation is conceivable, it cannot be confirmed. remainder of the hospitalization. The following medications An additional important historical finding for this dog was were subsequently administered over the next 2 h: ampicillin diagnosis of a congenital spinal malformation resulting in hind with sulbactam (Unasyn; West-Ward), 30 mg/kg BW, IV, pan- limb paralysis and urinary incontinence along with significant toprazole (Akorn, Lake Forest, Illinois, USA), 1 mg/kg BW, muscle atrophy and a resulting body condition score (BCS) of IV, maropitant citrate (Zoetis, Kalamazoo, Michigan, USA), 3/9. The dog had no other physical abnormalities or clinical 1 mg/kg BW, SQ, sucralfate (Sanofl-aventis, Kansas City, signs of illness leading up to the current incident. Missouri, USA), 500 mg, PO, and diphenhydramine (Benadryl; The dog was presented to the referring veterinarian within McNeil Consumer Healthcare, Fort Washington, Pennsylvania, 30 min of envenomation. It was apneic, bradycardic (heart USA), 2 mg/kg BW, PO, q12h. Blood test results (Critical Care rate: 20 beats/min), and was unresponsive to noxious stimuli. Xpress Stat Profile; Nova Biomedical, Waltham, Massachusetts, Emergency medical treatment consisted of intubation and USA) showed metabolic acidosis, hypoglycemia, and azotemia manual ventilation, epinephrine 0.02 mg/kg body weight (BW), (Table 1). Another venous blood gas analysis taken 7 h later IV, and diphenhydramine (Diphenhydramine injection; West- revealed unchanged kidney values but resolving mild metabolic Ward, Eatontown, New Jersey, USA), 7 mg/kg BW, IV and IM. acidosis and normoglycemia (Table 1). The dog remained stable Blood pressure measurement was too low to be read by Doppler. overnight. Its heart rate ranged between 88 and 115 beats/min A 4 mL/kg BW bolus of hydroxyethyl starch (Hetastarch; Teva with occasional ventricular premature contractions (VPC’s), Parental Medicines, Irvine, California, USA) and 20 mL/kg systolic blood pressure measurements ranging between 120 and BW bolus of lactated Ringer’s solution (LRS) were given, in 155 mmHg, and respiration rate that ranged between 28 and addition to dexamethasone SP (Bimeda-MTC Animal Health, 36 breaths/min. Due to the dog’s congenital spinal malforma- Cambridge, Ontario), 0.22 mg/kg BW, IV. After 10 min of tion, incontinence, and agitation on manipulation, and with resuscitation the dog began breathing spontaneously with a the risks of sedation required for urinary catheter placement,

hemoglobin saturation (SpO2) of 94% on 100% oxygen. After urinary output was not accurately monitored. A urine sample 20 min, the dog became responsive and was able to lift its head was not collected at this time for the same reasons. and swallow. The dog was placed in an oxygen cage while receiv- The following day oxygen treatment was discontinued and ing a maintenance IV dose of LRS of 50 mL/kg BW, q24h. The diphenhydramine 2.5 mg/kg BW was switched to the oral dog then developed bloody diarrhea. Metronidazole (Baxter route q12h. An intermittent supraventricular tachycardia with Healthcare, Deerfield, Illinois, USA), 10 mg/kg BW, IV, and occasional VPC’s occurred and spontaneously disappeared. A famotidine (West-Ward), 0.7 mg/kg BW, IV, were administered. hemogram showed leukocytosis with neutrophilia and lym- After several hours of treatment by the primary veterinarian, the phopenia along with a HCT of 0.39 (Table 2). The serum dog was referred to a tertiary emergency veterinary hospital. chemistry showed elevated liver enzyme levels, azotemia, and When the dog arrived at the referral hospital, it was obtunded mild hypoalbuminemia (Table 2). Both samples showed mild and severely hypotensive (blood pressure measurement too low hemolysis despite careful collection but the urine pads showed to be read). It had a respiratory rate of 104 breaths/min with no gross evidence of pigmenturia. increased effort, and cyanotic mucous membranes. The dog had The dog was cardiovascularly stable and continued to improve hematochezia that became melenic within 1 h. It was given oxy- clinically on day 2 (last day of hospitalization at the owner’s gen by facemask and LRS (20 mL/kg BW over 10 min). Soon request). Systolic blood pressure measurement ranged from

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Table 2. Complete blood cell count and blood analysis for the dog The patient did well at home over the next few months but on the second day of hospitalization and at the 3-day re-check at the referral hospital slowly lost weight due to progressive kidney disease. Home maintenance treatment consisted of subcutaneous fluids given Results Results daily and a kidney diet (Science Diet K/D; Hills Pet Food, (day 2) (3-day recheck) Reference range Topeka, Kansas, USA) mixed with an additional dog food diet WBC 22.13 20.23 5.0 to 13.0 3 109/L (Pro Plan Focus Adult Sensitive Skin and Stomach Formula REPORT CASE HCT 0.39 0.41 0.4 to 0.56 MCV 70.2 68.1 64.0 to 74.0 fL Dog Food; Nestle Purina, Wilkes-Barre, Pennsylvania, USA). MCH 23.1 23.7 22.0 to 26.0 pg The serum liver enzyme values became normal while the Plasma protein 55 66 51 to 78 g/L azotemia significantly worsened (BUN: 64.26 mmol/L, RR: Neutrophils 18 12 2.7 to 8.9 3 106/L Lymphocytes 0.88 2.0 0.9 to 3.4 3 106/L 3.57 to 7.14 mmol/L, creatinine 618.8 mmol/L, RR: 44 to Platelets 325 375 134 to 396 3 109/L 159.1 mmol/L) along with appearance of severe hyperphospha- ALP 118 79 8 to 114 U/L temia (5.55 mmol/L, RR: 0.8 to 2.19 mmol/L) when checked ALT 920 359 18 to 64 U/L almost 3 mo after the bee sting envenomation. AST 988 32 15 to 52 U/L The last recheck with the referring veterinarian was done Albumin 24 2.7 29 to 38 g/L Total protein 55 63 56 to 65 g/L 6 mo after the bee sting incident. Daily subcutaneous fluid BUN 18.2 44.2 2.8 to 8.9 mmol/L administration had been given at home since leaving the referral Creatinine 238.6 300.5 53 to 149 mmol/L hospital, with these treatments becoming significantly reduced WBC — white blood cells; HCT — hematocrit; MCV — mean corpuscular by the 3-month recheck and then subsequently increased. volume; MCH — mean corpuscular hemoglobin; ALP — alkaline phosphatase; ALT — alanine aminotransferase; AST — aspartate aminotransferase; BUN — blood Although blood testing at the time of the 6-month recheck urea nitrogen. showed marked azotemia (BUN 33.2 mmol/L, creatinine 371.28 mmol/L) and hyperphosphatemia (2.97 mmol/L; RR: 0.8 to 2.19 mmol/L) these values had improved from those done 3 mo previously. Blood pressure and urinalysis were 140 to 210 mmHg and enalapril (Wockhardt USA, Parsippany, not done but the most recent level of azotemia based on serum New Jersey, USA), 0.25 mg/kg BW, PO, q12h, was added. creatinine level showed the dog to be in IRIS Stage 3. Urine output was estimated by weighing urine pads, which indicated normal urine volume. A blood gas analysis performed Discussion at discharge showed improved azotemia (Table 1). Treatment The dog herein initially had anaphylactic shock due to bee stings at home was to consist of amoxicillin with clavulanic acid and soon afterward was found to have sustained significant (Clavamox; SmithKline Beecham Pharmaceuticals, Philadelphia, acute kidney injury. Moreover, with the blood test results 1 y Pennsylvania, USA), 23 mg/kg BW, enalapril, 0.23 mg/kg BW, earlier, it is possible that this case actually represents an acute or and omeprazole (DexcelPharma Technologies, Yokneam, Israel), chronic kidney injury but more substantiating evidence would 0.9 mg/kg BW, all PO, q12h. be required to assert this definitively. Anaphylaxis and acute The dog returned 3 d later for a recheck. Its time at home kidney injury have both been documented in South American showed a steady improvement in all aspects of the daily routine dogs following bee stings from Africanized honeybees (10). To while receiving the medications as directed. The dog was volun- our knowledge this is the first report of kidney injury following tarily eating small amounts of food, becoming more interactive, honeybee stings in North America. This dog was documented and its stool was returning to a normal color and consistency. as having mild to moderately elevated BUN and normal creati- The dog’s body weight was maintained at 10.8 kg and the chest nine almost 1 y prior to this incident. At that time it is possible auscultated normally. The hemogram showed improvement but that the dog was in IRIS Stage 1 with a lower than expected still showed a leukocytosis, and the serum chemistry showed creatinine level as a consequence of significant muscle atrophy improved albumin and liver enzyme parameters but worsening secondary to the rear limb paralysis and/or due to the dog’s diet azotemia (Table 2). A urinalysis showed isosthenuria (specific that incorporated table food, including high protein meats. gravity: 1.014) with an unremarkable sediment and trace pro- No blood tests, urinalysis, urine culture, or imaging were done tein along with a mildly elevated urine protein:creatinine ratio subsequently until the recent hospitalization and therefore pre- (UPC: 1.1). The owner was persuaded to hospitalize the dog existing chronic kidney disease cannot be confirmed. Following for overnight IV fluid treatment out of concern for premature the bee sting envenomation, the dog developed significant kid- discontinuation of treatment 3 d earlier. This was accomplished ney injury, resulting in the patient progressing to a stable IRIS with LRS at a rate of 125 mL/kg BW per day. Due to the history Stage 3 within a few months after the envenomation. In this of arrhythmias, a cardiology consultation, which included an case it is possible that the creatinine levels were artificially low echocardiogram, was done with the results showing no structural due to the dog’s muscle atrophy. It is possible that the kidney or rhythm abnormalities. During the dog’s overnight stay mean disease would be diagnosed as more advanced based on the arterial pressure (MAP) ranged from 107 to 111 mmHg, and IRIS staging system in a dog with a normal body condition. the urine output was again estimated as adequate by weigh- The kidney injury in this patient could have been caused by ing the urine pads. The dog was transferred to the referring prolonged hypotension secondary to anaphylaxis along with veterinarian the following morning for continued IV fluids at direct nephrotoxic effects of the venom (7,17). Additionally, the owner’s request. in light of the potential for angiotensin-converting-enzyme

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(ACE) inhibitors to negatively affect the kidney when there is injury and hemorrhage. No coagulation testing was done for this pre-existing reduced renal perfusion, the selection of this drug patient, and the melena resolved within 24 h. Since there were might have been a confounding factor to the dog’s already no other coagulopathy specific signs such as excessive bleeding compromised renal function. The kidney tubular degeneration from blood sampling sites and IV catheter or cutaneous signs, and necrosis in this dog can be associated with direct toxicity it is unlikely that a coagulopathy was the cause of the melena. of the venom in direct contact with the tubules, myoglobinuria However, a coagulation evaluation would have been justified and hemoglobinuria (although there was no evidence of gross to identify any abnormalities compatible with DIC (prolonged pigmenturia), as well as hypotension creating an ischemic-toxic partial thromboplastin time, prolonged prothrombin time, effect (10). In a retrospective study involving 19 dogs that died hypofibrinogenemia, and the detection of fibrin split products) due to intoxication from multiple Africanized bee stings, all of because some of these parameters can be abnormal without the dogs were found to have kidney degeneration and tubular clinical signs. RAPPORTCAS DE necrosis. This was associated with red or brown pigments, which Soon after presentation to the referring veterinarian follow- formed intratubular cylinders and/or accumulated within the ing envenomation, supraventricular tachycardia and ventricular tubular epithelial cells, different from what would be expected premature contractions were noted and resolved spontaneously. in purely hypotension related kidney injury. Additional findings Abnormal liver enzyme test results and cardiac arrhythmias have were focal areas of interstitial fibrosis (4/19) and glomerular been noted in human and veterinary medical literature and atrophy (3/19) (10). attributed to hepatocyte and cardiomyocyte necrosis resulting Anaphylaxis to Hymenoptera stings is a Type 1 IgE-mediated from direct toxic effects of the venom, in particular melittin

acute reaction that occurs within minutes of introduction of and phospholipase A2 (1,5,10,15,20–23). Additionally, local the venom. The reaction occurs when the animal has been ischemia, secondary to hypotension and hypovolemia are also previously exposed to the foreign antigen (Ag), stimulating considered important contributing factors. B-cells to create IgE antibody-secreting plasma cells. These IgE Signs of bee sting envenomation are most commonly associ- antibodies then attach to Fc receptors on the surface of tissue ated with the skin, gastrointestinal, cardiac, respiratory, neu- mast cells and circulating basophils, which is termed sensitiza- rologic, and ocular systems. In the cat, the respiratory and tion. When the venom is subsequently reintroduced, the Ag gastrointestinal systems are most often affected, but in the attaches to the membrane bound IgE on sensitized cells and dog signs most frequently involve the skin and gastrointestinal cross links the antibodies causing degranulation and release of systems (18). Treatment for all victims consists of intravenous pharmacologically active mediators such as histamine, serotonin, fluids, oxygen supplementation, epinephrine, corticosteroids, heparin, prostaglandins, leukotrienes, and platelet-activating fac- antihistamines, and analgesics (if needed). Epinephrine con- tor (3,18). Although anaphylaxis occurs very quickly, late phase tinues to be the most important life-saving treatment in ana- reactions known as biphasic reactions have been documented phylaxis because of its prevention of mast cell degranulation, its to occur in up to 20% of human patients (19). These reac- ability to cause vasoconstriction and increased blood pressure tions are reoccurrence of symptoms, delayed by up to 8 h after and heart rate, bronchodilatation, and maintaining endothe- resolution of the initial symptoms (19). Diphenhydramine was lial integrity. Risk factors for severe complications following administered to our patient for 24 h in an attempt to prevent Hymenoptera envenomations are not noted in veterinary medi- this biphasic reaction. cine. In human medicine with a larger population of patients The borderline low hematocrit was most likely caused by with cardiovascular disease, treatment with beta-blockers or hemodilution from fluid resuscitation and continued fluid angiotensin converting enzyme (ACE) inhibitors at the time of therapy along with the loss of blood into the digestive tract envenomation is known to worsen the risk of complications (3). due to a severe hypotensive episode and “shock gut” syndrome. These drugs can potentiate the negative effects of the mast-cell Hemolysis (as reported by the laboratory) and anemia were both mediators, prevent the breakdown of the neuropeptides and found early in the course of hospitalization of this dog. Acute bradykinin released from mast cells, and block the effects of intravascular hemolysis has been described in cases of bee sting epinephrine used to treat the patient (3). In humans, continued envenomation and is believed to be caused by cell membrane hospitalization even after successful treatment for the first 24 h

interruption by melittin and phospholipase A2 components of may be considered in order to monitor for biphasic and delayed the venom (10,17); however, given the lack of gross pigmentu- type hypersensitivity reactions (19,24). A biphasic reaction was ria, we have insufficient evidence to support this as a cause of reported in a dog which developed anaphylaxis following a the mild anemia or kidney injury in this case. The anemia along massive bee sting envenomation (16). That dog was treated and with hypoproteinemia could both be due to gastrointestinal released the same day after successful response to treatment but blood loss that occurred shortly after hospitalization. The mild within 48 h returned because of severe respiratory distress, vom- hypoglycemia and the leukocytosis can be related to the melena iting, and restlessness and was found to have developed ARDS and the possible association of mucosal barrier disruption with which was believed to have been due to the bee envenomation bacterial transmigration and sepsis early in the treatment period. 3 d earlier. In this case we had advised further hospitalization Melena is not uncommon in hypotensive animals and has with supportive care and treatment in the face of continued azo- been reported and accounted for by direct venom toxicity temia, but the owner declined. The owner and veterinary staff coagulopathy (10,20,21), which in this case could be related to were in repeated contact after the patient left the hospital. The the anaphylaxis and prolonged hypotension causing mucosal updates from home described the patient as symptomatically

268 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY improved prior to the 3-day recheck, but this short improve- 3. Casale TB, Burks AW. Hymenoptera-sting hypersensitivity. N Engl J ment was subsequently followed by a worsening azotemia. This Med 2014;370:1432–1439. 4. Schmacher M, Treten M, Egen R. Rate and quantity of delivery emphasizes the need for longer duration of hospitalization and of venom from honeybee stings. J Allergy Clin Immunol 1994;93: further testing when renal function is compromised. 831–835. This report describes an uncommon but important aspect of 5. Grisotto LSD, Mendes GE, Castro I, et al. Mechanisms of bee venom- induced acute renal failure. Toxicon 2006;48:44–54. Hymenoptera envenomation and raises concerns that are not 6. Lewis N, Racklyeft DJ. Mass envenomation of a mare and foal by bees. REPORT CASE typically part of routine client education, especially for poten- Aust Vet J 2014;92:141–148. tially high-risk dogs with existing kidney disease, co-existing 7. Bresolin NL, Carvalho FLC, Goes JEC, Fernandes VR, Barotto AM. Acute renal failure following massive attack by Africanized bee stings. heart disease and cardiac medications, liver disease, advanced Pediatr Nephrol 2002;17:625–627. age, and even those pets that have difficulty with ambulation 8. Langston K. Acute uremia. In: Ettinger SJ, Feldman EC, eds. Textbook as in this case. We now have an expanding population of aging of Veterinary Internal Medicine. 7th ed. St. Louis, Missouri: Saunders Elsevier, 2010:1969–1985. patients that fall into high-risk categories for complications 9. Newman SJ. The urinary system. In: Zachary JF, McGavin MD, eds. secondary to insect bite envenomation. There are several short- Pathologic Basis of Veterinary Disease. 5th ed. St. Louis, Missouri: Elsevier comings in this case including the lack of urine sampling, the Mosby, 2012:589–657. 10. Oliveira EC, Pedroso PMO, Meirelles AEWB, Pescador CA, Gouvea AS, lack of any overt hemolysis, the uncertainty of pre-existing Driemeier D. Pathological findings in dogs after multiple Africanized CKD, and the inability to observe the dog in the hospital for a bee stings. Toxicon 2007;49:1214–1218. longer period of time. Nevertheless the case serves to illustrate 11. Kolecki P. Delayed toxic reaction following massive bee envenomation. Ann Emerg Med 1999;33:114–116. the important pathophysiology that can occur with honeybee 12. Luskin AT, Luskin SS. Anaphylaxis and anaphylactoid reactions: envenomation. With consistent findings of hepatic, cardiac, Diagnosis and management. Am J Ther 1996;3:515–520. and renal injury in case reports (10,14–16,18,20–22) involving 13. Jung JW, Jeon EJ, Kim JW, et al. A fatal case of intravascular coagulation after bee sting acupuncture. Allergy Asthma Immunol Res 2012; Hymenoptera envenomations as well as concerns for cardiovas- 4:107–109. cular medications that enhance the effects of the venom and 14. Noble SJ, Armstrong PJ. Bee sting envenomation resulting in secondary diminish the effects of epinephrine, a cornerstone medication immune-mediated hemolytic anemia in two dogs. J Am Vet Med Assoc 1999;214:1026–1027. for anaphylaxis, clinician awareness, and owner education could 15. Nakamura RK, Fenty RK, Bianco D. Presumptive immune-mediated prove invaluable to many patients. thrombocytopenia secondary to massive Africanized bee envenomation This dog’s previous mild increase in BUN with normal in a dog. J Vet Emerg Crit Care 2013;23:652–656. 16. Walker T, Tidwell AS, Rozanski EA, Delaforcade A, Hoffman AM. creatinine could have represented an insidious chronic renal Imaging diagnosis: Acute lung injury following massive bee envenom- degenerative process that went into acute decompensation at the ation in a dog. Vet Radiol Ultrasound 2005;46:300–303. time of bee envenomation. In light of this, owners of pets that 17. Vetter RS, Visscher PK, Camazine S. Mass envenomations by honey bees and wasps. West J Med 1999;170:223–227. have pre-existing hepatic, cardiac, and/or renal disease should 18. Shmuel DL, Cortes Y. Anaphylaxis in dogs and cats. J Vet Emerg Crit be made aware of the potential complications that are associated Care 2013;23:377–394. with Hymenoptera stings. Although research is ongoing in the 19. Ellis AK, Day JH. Incidence and characteristics of biphasic anaphylaxis: A prospective evaluation of 103 patients. Ann Allergy Asthma Immunol area of antivenom, mellitin-binders, antagonists to mast-cell 2007;98:64–69. mediators, and anti-melittin antibodies, none of these therapies 20. Waddell LS, Drobatz KJ. Massive envenomation by Vespula spp. in are currently available to veterinary patients. Avoidance and two dogs. J Vet Emerg Crit Care 1999;9:67–71. 21. Cowell AK, Cowell RL, Tyler RD, Nieves MA. Severe systemic reac- education strategies that are commonly used in humans can be tions to Hymenoptera stings in three dogs. J Am Vet Med Assoc applied to veterinary patients, and are therefore our best proac- 1991;198:1014–1016. 22. Thomas E, Mandell DC, Waddell LS. Survival after anaphylaxis induced tive approach to this potentially deadly emergency. CVJ by a bumblebee sting in a dog. J Am Anim Hosp Assoc 2013;49: 210–215. References 23. Daher ED, Silva Junior GB, Bezerra GP, Pontes LB, Martins AMC, 1. Fitzgerald KT, Flood AA. Hymenoptera stings. Clin Tech Small Anim Guimarães JA. Acute renal failure after massive honeybee stings. Rev Pract 2006;21:194–204. Inst Med Trop S Paulo 2003;45:45–50. 2. Klotz JH, Klotz SA, Pinnas JL. Animal bites and stings with anaphy- 24. Kolecki P. Delayed toxic reaction following massive bee envenomation. lactic potential. J Emerg Med 2009;36:148–156. Ann Emerg Med 1999;33:114–116.

CVJ / VOL 58 / MARCH 2017 269 FOR PERSONAL USE ONLY Case Report Rapport de cas

Suspected bilateral phrenic nerve damage following a mediastinal mass removal in a 17-week-old pug

Mathieu Raillard, Pamela J. Murison, Ivan P. Doran

Abstract — The anesthetic management of a pediatric pug for removal of a mediastinal mass is described. During recovery from anesthesia, the dog’s respiratory pattern was compatible with bilateral diaphragmatic paralysis. Incidence, complications, possible treatments of phrenic nerve injury, problems of long-term mechanical ventilation, and alternative case management are discussed.

Résumé — Lésion bilatérale suspectée du nerf phrénique après l’ablation d’une masse médiastinale chez un Pug âgé de 17 semaines. Nous décrivons la gestion anesthésique d’un Pug pédiatrique présenté pour l’ablation d’une masse médiastinale. Durant le réveil après l’anesthésie, le profil respiratoire du chien était compatible avec la paralysie diaphragmatique bilatérale. L’incidence, les complications et les traitements possibles d’une blessure du nerf phrénique, les problèmes de la ventilation mécanique à long terme et les solutions pour la gestion du cas sont discutés. (Traduit par Isabelle Vallières) Can Vet J 2017;58:270–274

he phrenic nerves arise from the 5th to the 7th (occasionally This report describes the clinical signs and management of a Talso from the 4th) cervical nerves, and run caudally suspected bilateral PNI leading to diaphragmatic paralysis fol- dorsomedial to the brachial plexus in the fascia adjacent to lowing the removal of a large mediastinal mass in a young pug. the external jugular vein. These nerves then unite cranial to the thoracic inlet and pass through the thoracic inlet between Case description subclavian and omocervical arteries where they are joined by A 17-week-old pug weighing 2.5 kg was presented at Langford a fine sympathetic branch. Within the thoracic cavity, each Veterinary Services with a 3-day history of dyspnea. Since phrenic nerve lies in a narrow plica of pleura and spreads out adoption, the dog had had a history of regurgitation after over its respective half of the diaphragm, dividing into 3 main feeding, but this did not occur after ingestion of liquids. branches (ventral, lateral, and dorsal), which supply this muscle Dyspnea had developed acutely. Thoracic radiographs performed with motor and sensory fibers (1). The diaphragm is the most by the referring veterinary surgeon documented a marked important muscle of inspiration. When the diaphragm contracts, pleural effusion and a mass cranial to the heart. There had been its tendinous center pushes against the abdominal contents, moderate clinical improvement with furosemide and clavulanate elevating intra-abdominal pressure, which displaces the caudal ribs potentiated amoxicillin. outward. Its dome is pulled caudally, thus enlarging the thoracic On presentation, the dog was bright, alert, and playful. He cavity (2). When a phrenic nerve is sectioned, diaphragmatic was mildly tachypneic, with a moderately restrictive respira- contraction on that side ceases (3). tory pattern with an increased expiratory effort. On pulmo- Phrenic nerve injury (PNI) is a well-recognized complication nary auscultation, lung sounds could be heard over both lung of human thoracic surgery, especially of pediatric cardiac surgery fields. Hematology revealed a hematocrit of 27% with mild (4,5). To our knowledge PNI has not been reported in dogs. lymphocytosis [3.7 3 109/L; reference interval (RI): 0.70 to 3.60 3 109/L]. Alkaline phosphatase was mildy elevated School of Clinical Veterinary Science, University of Bristol, (6.7 mmol/L; RI: 3.0 to 5.0 mmol/L), a change consistent Langford, North Somerset, England. with the age of the dog. Jugular venous blood gas values and Address all correspondence to Dr. Mathieu Raillard; e-mail: electrolytes were within reference ranges. [email protected] Thoracic computed tomography (CT) identified a hetero- Dr. Raillard’s current address is Vetsuisse Faculty, University of geneous, soft-tissue attenuating cranial thoracic mediastinal Bern, Switzerland. Dr. Murison’s current address is Royal (Dick) mass. The heart was displaced caudally, the great vessels and School of Veterinary Studies, University of Edinburgh, Scotland. esophagus dorsally because of the significant space occupying Use of this article is limited to a single copy for personal study. effect. The right cranial lung lobe was collapsed and displaced Anyone interested in obtaining reprints should contact the caudally (Figure 1). An abdominal CT scan was unremarkable. CVMA office ([email protected]) for additional Anesthesia was scheduled for median sternotomy and mass copies or permission to use this material elsewhere. removal. A 22-gauge catheter was placed in the left cephalic

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A B C CASE REPORT CASE

Figure 1. A — transverse, B — dorsal, and C — sagittal CT scan images of a 17-week-old pug with mediastinal mass. Courtesy of the Imaging Service of Langford Veterinary Services.

vein. Methadone (Comfortan; Dechra Veterinary products, maintain the expired carbon dioxide tension (Pe’CO2) between 35 Shrewsbury, Shopshire, UK), 0.2 mg/kg body weight (BW), and 45 mmHg. Two hypodermic needles were positioned proxi- IV, was given as premedication. Oxygen was administered mal and distal on the medial aspect of the elbow, over the ulnar by facemask for 5 min before induction of anesthesia with nerve and connected to a peripheral nerve stimulator (Model 750 midazolam (Hypnovel; Roche Products, Welwyn Garden City, Digital; Dakmed, Buffalo, New York, USA). A bolus of 0.75 mg Hertfordshire, UK), 0.2 mg/kg BW, IV, and propofol titrated of atracurium (GlaxoSmithKline) was administered IV once IPPV to effect (Propoflo plus; Abbott Laboratories, Vanwall Road, had commenced, the peripheral nerve stimulator was positioned Maidenhead, UK), 2.4 mg/kg BW, IV. Oro-tracheal intubation and depth of anesthesia was stable. was readily performed with a 3.5-mm cuffed tube. Anesthesia Median sternotomy was performed and the mass was exposed. was maintained with sevoflurane (SevoFlo; Abbott Laboratories) There was no evidence of gross invasion into the great vessels

vaporized in oxygen and medical air (FiO2 60%) via a T-piece. or the lung lobes although the mass was firmly adherent to the During surgical preparation, the dog breathed spontaneously. cranial vena cava and brachiocephalic trunk. The left phrenic Analgesia was provided by paracetamol 25 mg (Perfalgan; nerve ran through the mass and, as it could not be separated, Bristol-Myers Squibb Pharmaceuticals, Uxbridge, Middlesex, was transected. The right phrenic nerve was adherent to the UK), 10 mg/kg BW, administered IV over 15 min before mass and was progressively freed from its adhesions. The mass surgery and fentanyl (Fentadon; Dechra Veterinary products), was carefully separated from the great vessels and removed. 5 mg bolus followed by infusion, 4 to 6 mg/kg BW per hour. Atracurium administration was repeated when 1 or more Hartmann’s solution, 5 mL/kg BW per hour, was infused with twitches returned on the train-of-four, at the dose of 0.25 mg a fluid pump throughout the procedure. A multiparametric IV (approximately every 25 min: 5 administrations in total). anesthetic monitor (Datex-Ohmeda S/5; GE Healthcare, A 10-French thoracic drain was inserted through the left tho- Little Chalfont, Buckinghamshire, UK) was used to monitor racic wall and the chest was closed in routine fashion. During pulse-oximetry (SpO2), electrocardiography (ECG), sidestream closure 0.75 mL of bupivacaine 0.25% (Marcain; AstraZeneca, capnography, and gas analysis (inspired and expired fractions London, UK) was infiltrated subcutaneously in the layers over of oxygen and isoflurane) sampled through an appropriate the sternum. The total blood loss was estimated to be less than connector placed between breathing system and endotracheal 10% of the dog’s blood volume. tube, spirometry, non-invasive blood pressure (oscillometry Before recovery, after return of 4 twitches on train-of-four, with a neonatal size 2 cuff, above the left tarsus), and esophageal 25 mg of glycopyrrolate (Martindale Pharmaceuticals, Romford, m temperature. The SpO2 sensor was placed on the tongue. Heart Essex, UK) and 50 g of neostigmine (Hameln pharmaceuticals, rate was calculated from the ECG and the lead II was displayed. Gloucester, UK) mixed in the same syringe were administered Several attempts to catheterize a dorsal metatarsal artery then IV to antagonize the effect of atracurium without inducing an auricular artery were unsuccessful. Clavulanate potentiated bradycardia. The fentanyl infusion was decreased from 6 to amoxicillin (Augmentin; GlaxoSmithKline, Brentford, 2 mg/kg BW per hour. The thoracic cavity was drained until Middlesex, UK), 50 mg, was administered IV every 90 min. negative pressure was achieved. Respiratory rate was initially Once in the operating theater, intermittent positive pressure decreased to 15 movements/min (mpm) then the dog was con- ventilation (IPPV) was applied using a small animal ventilator nected to a T-piece circuit and the lungs were inflated manually (Merlin; Vetronics, Abbotskerswell, Devon, UK) in volume cycle 2 to 3 times/min. At this stage anesthesia and surgery times mode. The tidal volume (VT) was initially set at 25 mL, the were 4 and 2.5 h, respectively. Once spontaneously breathing, inspiratory-expiratory ratio (I:E) was 1:2, and the peak inspiratory respiratory efforts appeared to be due solely to intercostal muscle pressure (PIP) was 9 cmH2O. Respiratory rate was adjusted to activity, whereas the diaphragm appeared to be inactive: the ribs

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were moving cranially and outwards and the abdomen looked tube’s position was altered slightly and the cuff re-inflated every “sucked in” during inspiration. Neostigmine and glycopyrrolate 6 h. The tube was also suctioned every 4 h and changed 12 h administration were repeated but no change was observed. The after intubation. The eyes were lubricated every 2 to 4 h and the fentanyl infusion was discontinued. An attempt to recover the mouth and prepuce were cleaned at the same time. dog was made; when he became intolerant to intubation (gag The following morning, an attempt to gradually wean off reflex and head movements), the trachea was extubated and ventilation was performed. Atracurium infusion was stopped, oxygen was administered via facemask. propofol infusion decreased to 0.2 mg/kg BW per minute, fentanyl After approximately 3 min, agonal gasps were observed. decreased to 2 mg/kg BW per hour. Considerable twitching and Peripheral pulses and an apex beat were no longer palpable. The movements were initially observed and, as this resembled seizure trachea was re-intubated and manual ventilation was instituted activity, midazolam 0.5 mg IV was administered. When 4 clear immediately; a cycle of external cardiac massage was performed twitches were observed on TOF, neostigmine, 0.05 mg/kg BW and RAPPORTCAS DE for approximately 2 min. Return of spontaneous circulation was glycopyrrolate, 0.01 mg/kg BW were administered together IV. then observed. The thoracic cavity was drained and approximately Propofol infusion was decreased to 0.1 mg/kg per minute. The 45 mL of blood were removed. Mechanical ventilation was then ventilator was initially set to assisted-mode then a T-piece was

re-initiated (VT, 35 mL; I:E, 1:2; PIP, 11 cmH2O; RR, 30 mpm). attached in order to observe bag movement. This was minimal. Initial Pe’CO2 was 105 mmHg but normalized within 5 min. As There was, as after surgery, large intercostal excursion but no the heart rate was 200 beats/min (bpm), a bolus of 20 mL of 6% evidence of diaphragmatic function. Ventilation was recommenced hydroxyethyl starch (Voluven 6% solution for infusion; Fresenius until the appropriate staff could contact the owners and the Kabi, Runcorn, Cheshire, UK) was administered IV. The fentanyl decision was made to perform euthanasia. infusion was also restarted. Microscopic appearance of the lesion was of extensive necrosis A second attempt to recover the dog was made 15 min later. and hemorrhage within a background matrix of reactive fibrous As the respiratory pattern was not improved compared to the first connective tissue. There was no clear evidence of neoplastic attempt and desaturation occurred, anesthesia was re-induced changes on histology; the etiology of the lesion was unclear. with propofol (2 mg, IV), the trachea was re-intubated and lung ventilation recommenced. The ventilator was set to inspiratory Discussion 2 assist mode with a threshold of 2 cmH2O with a VT of 40 mL. Two main mechanisms of PNI have been reported: hypothermia- This resulted in maintenance of SpO2 around 94% and moderate induced injury and mechanical trauma (5). The incidence of Pe’CO2 increase (65 mmHg). When the threshold for assisted PNI remains unknown; it has decreased from 24% to 73% to 2 2 ventilation was decreased below 2 cmH2O (e.g., 3 cmH2O or 0.46% to 20% after topical hypothermia — used as a method of . less), CO2 accumulation was marked (Pe’CO2 80 mmHg) and myocardial protection — was identified as an important etiology respiration was ineffective. As there appeared to be a gradually of PNI in the late 1980’s (6–9). There is in fact close contact decreasing efficacy of ventilation and a decision to maintain of the phrenic nerves with the pericardium in humans (10). IPPV overnight was made, volume-controlled ventilation was Mobilization of the internal mammary artery or direct surgical recommenced and the dog was moved to the intensive-care-unit trauma are described mechanical causes of PNI; indirect injuries (ICU). The dog was kept on the same ventilator used for the by sternal retractors or misuse of the electrocautery device are surgery in the ICU. also reported (5). The main consequence of PNI is diaphragmatic Anesthesia was initially maintained on sevoflurane vaporized paralysis of the side(s) concerned. Clinically, PNI can be

in oxygen and air (FiO2 60%); fentanyl infusion was continued. suspected by failure to wean from assisted ventilation, paradoxical The thoracic cavity was drained again (approximately 8 mL of movement of the epigastrium during spontaneous ventilation, blood were collected). A urinary catheter was placed and a new and elevation of the diaphragm on chest X-rays (11). Several attempt at placement of an arterial catheter (surgical approach methods of verification of PNI have been used: fluoroscopy to the femoral artery) was unsuccessful. Hematocrit and total (9), spirometry (12), transdiaphragmatic pressure studies (12), proteins were at this stage 23% and 40 g/L, respectively; ultrasound (13), and electrophysiological measurements (6,7,13). jugular venous blood gas analysis was unremarkable. The In this case neurotmesis of the left phrenic nerve was known dog was positioned in sternal recumbency. Sevoflurane from surgery and left hemidiaphragmatic paralysis was expected. administration was discontinued and replaced by a propofol The nature of the lesion of the right phrenic nerve was likely infusion (0.2 to 0.4 mg/kg BW per minute; Vetofol, Norbrook, mechanical (surgical trauma or stretching during the separation Carlisle, Cumbria, UK). Fentanyl was continued at 5 mg/kg BW of the nerve from the mass) and unpredictable. Our suspicion per hour, and a bolus of atracurium, 0.3 mg/kg BW, IV, was of bilateral diaphragmatic paralysis was clinical. A paradoxical

followed by an infusion at 0.2 mg/kg BW per hour. FiO2 was respiratory pattern and inability to wean off the ventilator guided decreased to 40% and IPPV (volume-controlled ventilation) was us towards continuing mechanical ventilation. adjusted to maintain normocapnia (VT, 35 mL; I:E, 1:2; PIP, Two aspects have to be considered for this animal’s prognosis:

11 cmH2O; RR, 30 mpm). Continuous monitoring included the potential respiratory performance of a dog with bilateral evaluation of the pulse quality, color of mucous membranes, diaphragmatic paralysis and the chances and timing of recovery ECG, pulse oximetry, capnography, and non-invasive blood of the phrenic nerve function. Electromyography of the pressure. Urine output was recorded every 2 h, temperature respiratory muscles in experimental dogs (14) demonstrated every 4 h. The cuff of the endotracheal tube was deflated, the an integrated strategy of respiratory muscles compensation for

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diaphragmatic paralysis with contribution of different respiratory pulmonary disease) and inadequate CO2 elimination (21). muscles (costal, crural, parasternal, and transversus abdominis) Cats and smaller dogs and animals less than 1 y old have been adjusted according to the degree of diaphragmatic dysfunction. shown to have poorer outcomes than larger young adult animals A physiological study on adult healthy dogs investigated the (21–23). The success of ventilation depends on the underlying effects of acute bilateral diaphragmatic paralysis (15). Silicone pathology (21). Long-term ventilation is generally more com- cuffs were implanted around each phrenic nerve and attached to plex and the rate of ventilator associated complications is high REPORT CASE an injection line tunnelled subcutaneously for local anesthetic (21,22,24–26). Long-term ventilation is expensive and requires injection. Spirometry and alveolar partial pressure of CO2 constant monitoring and staff commitment. For these reasons were assessed. Unilateral diaphragmatic paralysis resulted in it should not be undertaken lightly. In this case, many factors increased rib cage contribution and little effect on ventilation. of poor prognosis were present: the dog was pediatric and very Bilateral diaphragmatic paralysis resulted in marked abdominal small. He was also brachycephalic which, in case of recovery, paradoxical breathing and increased rib cage expansion. There would have resulted in a potentially more critical weaning (27). was no effect on resting ventilation, but a decrease in tidal and However, if the choice of the owners had been to continue treat- minute volume and a mild increase in PACO2 during REM ment, long-term ventilation to allow recovery was an acceptable (rapid eye movement) sleep. Adult healthy experimental dogs alternative. In that case, regular electrophysiologic study of the of this study seemed to be able to cope well with bilateral PNI, phrenic nerve conduction could have been used to monitor the therefore, attempting to recover our dog despite the PNI was phrenic nerve recovery and set endpoints to the ventilation. not unreasonable, independent of whether PNI was unilateral Diaphragmatic plication could have been considered at a later or bilateral. It has been shown that hemidiaphragmatic paralysis stage if right diaphragmatic function was recovered but weaning in the dog has a direct detrimental effect on the expansion of from ventilation failed again. both lungs (16). In this case the dog was both pediatric and Bilateral PNI is rare in humans and, to our knowledge, not brachycephalic. In pediatric animals, the pulmonary reserve reported in dogs. This case was particularly challenging because is minimal and the thoracic wall is more compliant, which of his breed, age, small size, and the severity of the lesions he results in less efficient ventilation and greater work of breathing exhibited after surgery. Although it could have been managed (17). In addition, post-anesthetic respiratory complications are differently, euthanasia was always the most likely outcome. common in brachycephalic dogs (18). This could explain why our attempt to wean this dog off the ventilator after anesthesia Acknowledgment was unsuccessful. The authors thank Jenny Reeve for her contribution to the case A prospective study using electrophysiologic measurements management. of phrenic nerve latency in infants undergoing cardiac surgery investigated the incidence of PNI and its effects on References morbidity and prognosis (7). Findings were that PNI led to . 1 Kitchell RL, Evans HE. The spinal nerves. In: Evans HE, ed. Miller’s an increased duration of mechanical ventilation after surgery. Anatomy of the Dog. 3rd ed. Philadelphia, Pennsylvania: Saunders, Post-surgery, approximately 1/3 of the patients with PNI had 1993:829–893. 2. Robinson NE. Overview of respiratory function: Ventilation of the lung. recovered diaphragmatic function within 1 mo and 2/3 within In: Cunningham JG, Klein BG, eds. Textbook of Veterinary Physiology. 3 mo. Spontaneous recovery is therefore possible, but it is 3rd ed. Philadelphia, Pennsylvania: Saunders, 2002:468–478. unpredictable and rarely happens early (13,19). In this case, 3. Warner WP. Phrenicotomy in traumatic injury to the chest. Can Med Assoc J 1926;16:427–428. the recovery of the left phrenic nerve was impossible as a whole 4. Ostrowska M, de Carvalho M. Prognosis of phrenic nerve injury fol- section had been removed; recovery of the right side may have lowing thoracic interventions: Four new cases and a review. Clin Neurol been possible as neuropraxia or axonotmesis were more likely. Neurosurg 2012;114:199–204. 5. Aguirre VJ, Sinha P, Zimmet A, Lee GA, Kwa L, Rosenfeldt F. Phrenic In cases of traumatic PNI, return of normal diaphragmatic nerve injury during cardiac surgery: Mechanisms, management and function could be expected within 6 to 12 mo in adults (20). In prevention. Heart Lung Circ 2013;22:895–902. human medicine, the management of diaphragmatic paralysis is 6. Merino-Ramírez MA, Juan G, Ramón M, Cortijo J, Morcillo EJ. Diaphragmatic paralysis following minor cervical trauma. Muscle Nerve controversial: options are continuation of mechanical ventilation 2007;36:267–270. until recovery of the phrenic nerve function or diaphragmatic 7. Ross Russell RI, Helms PJ, Elliott MJ. A prospective study of phrenic plication, especially in cases of hemidiaphragmatic paralysis nerve damage after cardiac surgery in children. Intensive Care Med 2008;34:728–734. (13,19). Diaphragmatic plication was unlikely to be helpful in 8. Tripp HF, Bolton JW. Phrenic nerve injury following cardiac surgery: this case because of the bilateral PNI. Furthermore, a 15-hour A review. J Card Surg 1998;13:218–223. period of ventilation was unlikely to be sufficient to permit 9. Zhang YB, Wang X, Li SJ, Yang KM, Sheng XD, Yan J. Postoperative diaphragmatic paralysis after cardiac surgery in children: Incidence, nerve recovery. With hindsight, euthanasia after the first attempt diagnosis and surgical management. Chin Med J 2013;126:4083–4087. to recover the dog from anesthesia was a reasonable option given 10. Jiang S, Xu WD, Shen YD, Xu JG, Gu YD. An anatomical study of the its poor prognosis of recovery and the increased risk factors full-length phrenic nerve and its blood supply: Clinical implications for endoscopic dissection. Anat Sci Int 2011;86:225–231. associated with prolonged mechanical ventilation. 11. Joho-Arreola A, Bauersfeld U, Stauffer U, Baenziger O, Bernet V. Prolonged mechanical ventilation (. 24 h) has been Incidence and treatment of diaphragmatic paralysis after cardiac surgery described in dogs using a variety of anesthetic techniques and in children. Eur J Cardiothorac Surg 2005;27:53–57. 12. Chandler KW, Rozas CJ, Kory RC, Goldman AL. Bilateral diaphrag- ventilation strategies. Indications are generally divided into matic paralysis complicating local cardiac hypothermia during open 2 categories: inadequate blood oxygenation (parenchymal heart surgery. Am J Med 1984;77:243–249.

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13. Lemmer J, Stiller B, Heise G, et al. Postoperative phrenic nerve palsy: Early clinical implications and management. Intensive Care Med 2006; 32:1227–1233. 14. Katagiri M, Young RN, Platt RS, Kieser TM, Easton PA. Respiratory muscle compensation for unilateral or bilateral hemidiaphragm paralysis in awake canines. J Appl Physiol 1994;77:1972–1982. 15. Stradling JR, Kozar LF, Dark J, Kirby T, Andrey SM, Phillipson EA. Effect of acute diaphragm paralysis on ventilation in awake and sleeping dogs. Am Rev Respir Dis 1987;136:633–637. 16. de Troyer A, Leduc D, Cappello M. Bilateral impact on the lung of hemidiaphragmatic paralysis in the dog. Respir Physiol Neurobiol 2009; 166:68–72. 17. Pettifer GR, Grubb TL. Neonatal and geriatric patients. In: Tranquili WJ, Thurmon JC, Grimm KA, eds. Lumb and Jones’ Veterinary Anesthesia and Analgesia. 4th ed. Ames, Iowa: Blackwell Publishing, 2007:985–991. 18. Senn D, Sigrist N, Forterre F, Howard J, Spreng D. Retrospective evaluation of postoperative nasotracheal tubes for oxygen supplementation in dogs following surgery for brachycephalic syndrome: 36 cases (2003–2007). J Vet Emerg Crit Care 2011;21:261–267. 19. de Leeuw M, Williams JM, Freedom RM, Williams WG, Shemie SD, McCrindle BW. Impact of diaphragmatic paralysis after cardiothoracic surgery in children. J Thorac Cardiovasc Surg 1999;118:510–517. 20. Iverson LI, Mittal A, Dugan DJ, Sampson PC. Injuries to the phrenic nerve resulting in diaphragmatic paralysis with special reference to stretch trauma. Am J Surg 1976;132:263–269. 21. Hopper K, Haskins SC, Kass PH, Rezende ML, Aldrich J. Indications, management, and outcome of long-term positive-pressure ventilation in dogs and cats: 148 cases (1990–2001). J Am Vet Med Assoc 2007; 230:64–75. 22. King LG, Hendricks JC. Use of positive-pressure ventilation in dogs and cats: 41 cases (1990–1992). J Am Vet Med Assoc 1994;204:1045–1052. 23. Lee JA, Drobatz KJ, Koch MW, King LG. Indications for and outcome of positive-pressure ventilation in cats: 53 cases (1993–2002). J Am Vet Med Assoc 2005;226:924–931. 24. Beal MW, Paglia DT, Griffin GM, Hughes D, King LG. Ventilatory failure, ventilator management, and outcome in dogs with cervical spinal disorders: 14 cases (1991–1999). J Am Vet Med Assoc 2001; 218:1598–1602. WHEN IT COMES TO SAFETY,1,2 25. Bruchim Y, Aroch I, Sisso A, et al. A retrospective study of positive pressure ventilation in 58 dogs: Indications, prognostic factors and WE SEE EYE TO EYE outcome. J Small Anim Pract 2014;55:314–319. 26. Campbell VL, King, LG. Pulmonary function, ventilator management, and outcome of dogs with thoracic trauma and pulmonary contusions: Veraf ox® delivers proven ocular safety 10 cases (1994–1998). J Am Vet Med Assoc 2000;217:1505–1509. and broad-spectrum coverage 27. Hoareau GL, Mellema MS, Silverstein DC. Indication, management, and outcome of brachycephalic dogs requiring mechanical ventilation. in an easy-to-use oral suspension. J Vet Emerg Crit Care 2011;21:226–235.

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Computed tomographic and angiographic assessment of spinal extradural arteriovenous fistulas in a dog

Simona Morabito, Edoardo Auriemma, Paolo Zagarella, Edy Mercuriali, Oriol Domenech, Gualtiero Gandini, Teresa Gagliardo, Eric Zini, Swan Specchi

Abstract — A 6-month-old German shepherd dog was presented for progressive paraparesis. Multiple arteriovenous fistulae and hyperostosis of the thoracic vertebrae with secondary thoraco-lumbar spinal cord compression were diagnosed. Arteriovenous spinal fistula is a rare condition but should be considered as a differential diagnosis in young dogs with progressive paraparesis.

Résumé — Évaluation par tomodensitométrie et angiographie de fistules artérioveineuses extradurales spinales chez un chien. Un chien Berger allemand âgé de 6 mois a été présenté pour une paraparésie progressive. De nombreuses fistules artérioveineuses et de l’hyperostose des vertèbres thoraciques avec une compression de la colonne vertébrale thoraco-lombaire secondaire ont été diagnostiquées. Les fistules spinales artérioveineuses sont une rare affection mais elles devraient être considérées comme un diagnostic différentiel chez les jeunes chiens atteints de paraparésie progressive. (Traduit par Isabelle Vallières) Can Vet J 2017;58:275–279

Case description multidetector computed tomographic (MDCT) study of the thoracolumbar vertebral column was performed for further 6-month-old German shepherd male dog was evaluated evaluation. Images were obtained with a 4-slice helical MDCT for progressive paraparesis. Neuroanatomic localization A scanner (Light Speed; GE Medical Systems, Bergamo, Italy). was consistent with a T3-L3 myelopathy. Differential diag- The dog was positioned in dorsal recumbency, and an MDCT noses included congenital disease such as vertebral malforma- study was performed in helical modality, 120 kV, 200 mA, tion (hemivertebrae, butterfly vertebrae, spina bifida) with 0.7 s rotation tube, 1.5 pitch, and 7.5-mm slice thickness, secondary reduction of the vertebral canal diameter, arachnoid reconstructed with a standard algorithm. Arterial and venous diverticula, vascular malformation, inflammatory disease, or post-contrast images were acquired following the injection of juvenile neoplasia of the spinal cord at T3-L3. An angiographic 2.0 mL/kg body weight (BW) of iodinated nonionic contrast medium (Omnipaque 350 mg/mL; GE Healthcare, Milan, Italy) Department of Diagnostic Imaging (Morabito, Auriemma, via a 22-gauge catheter into the right cephalic vein at a 3 mL/s Specchi), Department of Neurology (Zagarella, Mercuriali), and infusion rate, through a computed tomography power injector Department of Internal Medicine (Zini), Istituto Veterinario system (Medrad; Medrad Italia, Cava Manara, Italy). During the di Novara, Strada Provinciale 9, 28060, Granozzo con arterial phase there was concomitant enhancement of both aorta Monticello (NO), Italy; Department of Veterinary Medical and azygos vein (Figures 1–3). The azygos vein was markedly Sciences, University of Bologna, Via Tolara di Sopra 50, increased in size being roughly the same diameter as the aorta. Ozzano dell’Emilia, Italy (Gandini); Clinic for Small Animal Moreover, a network of homogeneously enhancing tortuous Internal Medicine, University of Zurich, Winterthurerstrasse vessels was observed ventrally and laterally to the vertebral bod- 260, 8057 Zurich, Switzerland and Department of Animal ies of T11-L1 (anastomosing with the intercostal arteries and Medicine, Production and Health, University of Padova, viale veins). A direct anastomosis between the intercostal artery and dell’Università 16, 35020 Legnaro (PD), Italy (Zini); Palermovet vein was observed at T11-T12; at this level the right interverte- Clinic, Viale Regione Siciliana Sud-Est 4111, 90125 Palermo, bral vein was increased in size, displacing and compressing the Italy (Gagliardo). spinal cord dorsally and to the left (Figure 1). Congestion of the Address all correspondence to Dr. Swan Specchi; e-mail: right portion of the venous plexus was observed up to the level [email protected] of the third thoracic vertebra (Figure 4). The right portion of Use of this article is limited to a single copy for personal study. the vertebral bodies and arches of T11-L1 were thickened with Anyone interested in obtaining reprints should contact the a heterogeneous appearance due to the presence of multiple CVMA office ([email protected]) for additional ill-defined areas of decreased bone attenuation and peripheral copies or permission to use this material elsewhere. increased bone attenuation (Figure 5). These changes were more

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Figure 1. Transverse contrast-enhanced CT image with soft tissues (A) and 3-dimensional surface rendered transverse perspective images of T12 (B). The images show the increased volume of the azygos vein (arrow) and the presence of an arteriovenous fistula (asterisk) within the spinal canal, which laterally displaces and compresses the spinal cord. The arrowhead (1B) indicates an enlarged invertebral vein.

A B

Figure 2. Three-dimensional surface rendered MDCT angiography of the thoracic vertebral column of the present dog (A) compared to that of a healthy dog (B); the diameter of the thoracic portion of the azygos vein is increased in the former (asterisk). Note the enlarged intercostal veins (arrowhead).

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A B CASE REPORT CASE

Figure 3. Selective aortic angiography. Note the multiple arteriovenous fistulae (arrow at T13 and arrowhead at T11) with early increased enhancement of the azygos vein (asterisk). severe at the level of L1, leading to stenosis of the vertebral canal walls (9–11). Our case presents important similarities with feline and secondary spinal cord compression (Figure 4). A diagnosis vertebral angiomatosis and this disease should be considered of spinal vascular malformation with arterio-venous fistulae as a possible differential diagnosis in our dog. Unfortunately, was made. histological evaluation was not performed. Embolization of the anomalous vessel was considered as a In humans, vascular malformations of the spinal cord are con- possible therapeutic procedure. In order to identify the arterial- sidered uncommon lesions, representing 3% to 16% of all spinal ized vein for embolization, a selective aortic angiography was space-occupying lesions (12). Spinal arteriovenous fistulae can performed. During general anesthesia, percutaneous vascular cause neurological signs due to hemorrhage, venous congestion, access through the femoral artery was obtained. An angiographic mass effect, and “vascular steal” phenomenon (13). In human catheter was positioned in the abdominal aorta at the level of medicine, spinal cord arteriovenous fistulae have been previously T11-T12 transition. Angiograms were performed by manual classified into 4 types: dural, intramedullary, perimedullary and bolus injection of 1 mL/kg BW of iodinated nonionic contrast extradural arteriovenous fistulae (14). The clinical and imaging medium (Omnipaque 350 mg/mL). Multiple arteriovenous findings in the dog herein were similar to the one reported in spinal fistulae were observed at T10-T13 (Figure 5) and due to humans with extradural arteriovenous fistulae. The extradural the complexity of the vascular malformation a single emboliza- fistulae are located in the epidural space, vascularized by dural tion was considered not feasible. The owners refused further or epidural branches of segmental arteries, and drain primarily treatment and the dog was discharged from our hospital. into epidural venous plexuses (15–17). The increase in spinal venous pressure due to arterialization Discussion leads to decreased drainage of normal spinal veins and venous Vascular malformations of the spinal cord are rare in dogs. congestion with intramedullary edema. This congestion leads to There are 8 case reports of vascular malformations leading to chronic hypoxia and progressive myelopathy (16). In this report, myelopathy in dogs, including cavernous angioma, intramedul- the spinal cord was compressed by the congestion of the internal lary hamartoma, arteriovenous malformation in the cervical and vertebral venous plexus, probably leading to both compressive thoracolumbar region, lumbosacral angioectatic malformation, and hypoxic damage (17,18). Moreover, multifocal hyperostosis ectatic radicular arteries due to aplasia of the right subclavian of the vertebral arches leading to stenosis of the vertebral canal artery, intramedullary cavernous malformation, and intramed- was also observed, exacerbating the spinal cord compression. ullary vascular cyst-like anomaly (1–8). Vertebral angiomatosis We consider that these changes were likely related to chronic has been described in young cats. It is considered a rare vascular hypoxic bone damage with infarcts and secondary remodelling. malformation, characterized by multiple angiomas which are In humans, this condition has been reported in the lower limbs non-neoplastic tumors that form blood vessels and fistulae. of pediatric patients with angio-osteohypertrophic syndrome, Histologically these lesions are benign proliferations of blood a congenital vascular bone malformation which results in over- vessels of undetermined origin with well-differentiated vascular growth of the affected limb (18). In a recent report, a German

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Figure 4. Dorsal MPR MDCT angiography image showing Figure 5. Transverse CT image with bone kernel of T12 showing multiple paravertebral fistulae with secondary vertebral venous the thickening of the vertebral body and arch with secondary plexus congestion (asterisk) and secondary spinal cord reduction of the vertebral canal diameter. compression.

shepherd puppy presented for an arteriovenous fistula on the 4. Hayashida E, Ochiai K, Kadosawa T, Kimura T, Umemura T. distal aspect of the right pes had hyperostotic changes, similar Arteriovenous malformation of the cervical spinal cord in a dog. J Comp Pathol 1999;121:71–76. to our dog (19); these hyperostotic changes were considered to 5. Cordy DR. Vascular malformations and hemangiomas of the canine be secondary to chronic hypoxia. spinal cord. Vet Pathol 1979;6:275–282. In human medicine, the gold standard diagnostic procedure 6. Westworth DR, Vernau KM, Cullen SP. Vascular anomaly causing subclavian steal and cervical myelopathy in a dog: Diagnosis and to characterize arteriovenous malformations is angiography that endovascular management. Vet Radiol Ultrasound 2006;47:265–269. provides the necessary information to plan treatment, usually 7. MacKillop E, Olby NJ, Linder KE, Brown TT. Intramedullary cavern- through embolization of the fistula (20–21). The aim of the ous malformation of the spinal cord in two dogs. Vet Pathol 2007;44: 528–532. treatment is the occlusion of the fistula with 2 main options: 8. Alexander K, Huneault L, Foster R, D’Anjou MA. Magnetic resonance surgical occlusion of the arterialized vein or endovascular imaging and marsupialization of a hemorrhagic intramedullary vascular therapy using a liquid embolic agent through superselective anomaly in the cervical portion of the spinal cord of a dog. J Am Vet Med Assoc 2008;232:399–404. catheterization of the arterialized vein. Surgical obliteration or 9. Wells MY, Weisbrode SE. Vascular malformations in the thoracic ver- excision of intramedullary malformations and perimedullary tebrae of three cats. Vet Pathol 1987;24:360–361. fistulas is difficult, especially if the lesion lies on or within the 10. Kloc PA 2nd, Scrivani PV, Barr SC, et al. Vertebral angiomatosis in a cat. Vet Radiol Ultrasound 2001;42:42–45. ventral aspect of the spinal cord. Therefore, endovascular treat- 11. Schur D, Rademacher N, Vasanjee S, McLaughlin L, Gaschen L. Spinal ment is the treatment of choice (22). In our case, there were too cord compression in a cat due to vertebral angiomatosis. J Feline Med many fistulae that needed to be embolized with selective angi- Surg 2010;12:179–182. 12. Da Costa L, Dehdashti AR, Terbrugge KG. Spinal cord vascular shunts: ography and the owners declined any further treatment. In the Spinal cord vascular malformations and dural arteriovenous fistulas. event of successful treatment of the fistula, hemilaminectomy Neurosurg Focus 2009;26:E6 1–9. would have been necessary to reduce the compression of the 13. Yamamoto S, Kim P. Spinal ateriovenous fistulae and arteriovenous malformations — Complicated vasculature and surgical imaging. In: spinal cord secondary to the vertebral hyperostosis. Tjoumakaris S, ed. Arteriovenous Fistule Diagnosis and Management, In summary, we describe for the first time a spinal extra-dural Epub July 10, 2013. Available from: http://www.intechopen.com/books/ vascular malformation consistent with multiple arteriovenous arteriovenous-fistulas-diagnosis-and-management/spinal-arteriovenous- fistulae in a young dog resembling feline vertebral angiomatosis fistulas-and-arteriovenous-malformations-complicated-vasculature-and- surgical-i Last accessed January 3, 2017. and we highlight the importance of MDCT angiography in 14. Spetzler RF, Detweiler PW, Riina HA, Porter RW. Modified classifica- combination with interventional angiographic procedure for tion of spinal cord vascular lesions. J Neurosurg 2002;96:145–156. the best treatment choice. 15. Rodesch G, Lasjaunias P. Spinal cord arteriovenous shunt: From imaging to management. Eur J Radiol 2003;46:221–232. 16. Rangel-Castilla LR, Holman PJ, Krishna C, Trask TW, Klucznik RP, References Diaz OM. Spinal extradural arteriovenous fistulas: A clinical and 1. Westworth DR, Sturges BK. Congenital spinal malformations in small radiological description of different types and their novel treatment animals. Vet Clin North America Small Anim Pract 2010;40:951–981. with Onyx. J Neurosurg Spine 2011;15:541–549. 2. Zaki FA. Vascular malformation (cavernous angioma) of the spinal cord 17. Takai K, Taniguchi M. Comparative analysis of spinal extradural arterio- in a dog. J Small Anim Pract 1979;20:417–422. venous fistulas with or without intradural venous drainage: A systematic 3. Sanders SG, Bagley RS, Gavin PR, Konzik RL, Cantor GH. Surgical literature review. Neurosurgical Focus 2012;8:32–35. treatment of an intramedullary spinal cord hamartoma in a dog. J Am 18. Mattassi R, Vaghi M. Bone syndrome-angio-osteodystrophy: Current Vet Med Assoc 2002;221:659–661. concept Phlebology 2007;22:287–290

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19. Shaikh LS, Holmes SP, Selberg KT, et al. Imaging diagnosis — 21. Krings T, Lasjaunias PL, Hans FJ, et al. Imaging in spinal vascular Radiographic, ultrasonographic, computed tomographic and fluoro- disease. Neuroimaging Clin N Am 2007;17:57–72. scopic appearance of a distal pelvic limb arteriovenous malformation in 22. Van Dijk JM, TerBrugge KG, Willinsky RA, Farb RI, Wallace MC. a young German shepherd dog. Vet Rad Ultrasound 2016;57:E16-21. Multidisciplinary management of spinal dural arteriovenous fistulas: DOI: 10.1111/vru. 12290. Clinical presentation and long-term follow-up in 49 patients. Stroke 20. Krings T, Geibprasert S. Spinal dural arteriovenous fistulas. AJNR Am 2002;33:1578–1583. J Neuroradiol 2009;30:639–648. CASE REPORT CASE

Answers to Quiz Corner Les réponses du test éclair

1. B) The ACTH stimulation test should be performed to make the 3. D) 90% of osteosarcoma patients die or are euthanized within diagnosis of hyperadrenocorticism. Answer C is not useful for 1 year of diagnosis because of complications associated with evaluating the adrenal response to ACTH production; D is a pulmonary metastasis. differentiation test, not a screening test; A and E are used for D) 90 % des patients souffrant d’ostéosarcome meurent ou evaluating thyroid hormone production, not the adrenal axis. sont euthanasiés dans l’année suivant l’établissement du B) Le test de stimulation de l’ACTH doit être effectué pour diagnostic à cause des complications associées aux métastases permettre le diagnostic d’hyperadrénocorticisme. Le choix C pulmonaires. n’est pas utile pour évaluer la réponse surrénalienne à la 4. E) Average daily gain and feed conversion is used as measures production d’ACTH; la réponse D est un test de différenciation of performance in the feedlot industry while rolling herd milk et non un test de dépistage; les réponses A et E sont utilisées production is used in the dairy industry. pour l’examen de la production de l’hormone thyroïdienne et E) Le gain de poids moyen quotidien et la conversion alimentaire non de l’axe surrénalien. sont utilisés comme mesures de performance dans l’industrie 2. B) Low thyroid hormone levels without an elevation of TSH bovine en parc d’engraissement alors que la production laitière are normal in sighthound breeds, and do not suggest breed- moyenne du troupeau est utilisée dans l’industrie laitière. ing problems. The lack of thyroglobulin autoantibody indi- 5. B) A therapeutic dose of lidocaine administered IV results in cates that this dog most likely does not have lymphocytic analgesia. thyroiditis. B) Une dose thérapeutique de lidocaïne administrée par voie B) De faibles taux de l’hormone thyroïdienne sans élévation de la intraveineuse produit de l’analgésie. TSH sont normaux pour le groupe de chiens chasseurs à vue et ne suggèrent pas de problèmes de reproduction. Le manque d’anticorps de thyroglobuline indique que cette chienne ne souffre probablement pas de thyroïdite lymphocytaire.

quiz corner is generously sponsored by le test éclair est généreusement commandité par A: With trusted NOBIVAC® specialty vaccines, that provide demonstrated efficacy against specific pathogens, and offer unique features that set them apart in their category. www.nobivac.ca www.merck-animal-health.ca ® ® ® ® ® NOBIVAC LEPTO4 NOBIVAC LYME NOBIVAC INTRA-TRAC 3 ADT NOBIVAC 2-FeLV Nobivac® is a registered trademark of Intervet International B.V. Used under license. MERCK® is a registered trademark of Merck Canada Inc. © 2016 Intervet Canada Corp. All rights reserved.

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CVJ / VOL 58 / MARCH 2017 279 FOR PERSONAL USE ONLY Case Report Rapport de cas

Diagnosis and treatment of massive porcupine quill migration in a dog

Kathryn Flesher, Nathaniel Lam, Taryn A. Donovan

Abstract — A 5-year-old spayed female Boston terrier mixed breed dog was presented with porcupine quill migration. The quills were difficult to detect directly using computed tomography and magnetic resonance imaging. This case highlights difficulties faced in detecting porcupine quills with current diagnostic imaging modalities and describes surgical and medical management of a patient with massive quill migration.

Résumé — Diagnostic et traitement de la migration massive des aiguilles de porc-épic chez une chienne. Une chienne Boston terrier de race croisée âgée de 5 ans a été présentée avec une migration des aiguilles de porc- épic. Les aiguilles ont été difficiles à détecter directement en utilisant une tomodensitométrieet une imagerie par résonance magnétique. Ce cas souligne les difficultés rencontrées lors de la détection des aiguilles de porc-épic avec les modalités d’imagerie de diagnostic actuelles et il décrit la gestion chirurgicale et médicale d’une patiente atteinte d’une migration massive d’aiguilles. (Traduit par Isabelle Vallières) Can Vet J 2017;58:280–284

lthough porcupine quill injuries are common, massive New York, New York, USA), 15 mg/kg body weight (BW), PO, A quill migration is a rare but significant cause of morbid- q12h, carprofen (Pfizer Animal Health), 5 mg/kg BW, PO, ity and mortality in humans and animals. The authors are not q12h, and tramadol (Caraco Pharmaceutical, Detroit, Michigan, aware of any previous reports of multi-systemic quill migration USA), 3 mg/kg BW, PO, q12h, as well as triple antibiotic in which the limitations of detecting porcupine quills with ophthalmic solution (Bausch & Lomb, Tampa, Florida, USA), diagnostic imaging have been highlighted. This case describes 2 drops instilled into the right eye q8h, to treat a corneal ulcer. both surgical and medical approaches to treatment and discusses Upon presentation to the Animal Medical Center 5 d after the merits of both. the injury, the dog was bright, alert, and responsive. Extraocular swelling around the left eye and a right corneal opacity were Case description noted but fluorescein staining of the cornea failed to detect A 5-year-old spayed female Boston terrier mixed breed dog ulceration. There were numerous dermal irregularities suspected weighing 17 kg was referred to the Animal Medical Center, to be quill remnants located on the right dorsolateral thorax and New York, New York for evaluation of extraocular pain and dorsum. The remainder of the physical examination was unre- swelling associated with a recent porcupine quill injury. The markable and the patient was admitted for a computed tomogra- dog had originally been presented to her referring veterinarian phy (CT) scan in an attempt to locate quill tracts and potentially 5 d earlier, at which time more than 100 quills were removed remove any detectable quills associated with the extraocular under anesthesia from the superficial tissues of the head, limbs, swelling. The patient was premedicated with methadone (Mylan chest, and flank. At that time it was noted that many quills Institutional, Rockford, Illinois, USA) 0.2 mg/kg BW, IM, could be palpated beneath the skin. The dog was discharged and glycopyrrolate (West Ward, Eatontown, New Jersey, USA) with oral amoxicillin and clavulanic acid (Pfizer Animal Health, 0.01 mg/kg BW, IM, and then induced with propofol (Fresenius Kabi USA, Lake Zurich, Illinois, USA), 6 mg/kg BW, IV, and midazolam (West Ward), 0.5 mg/kg BW, IV. A CT scan of the Veterinary Specialists & Emergency Services, 825 White Spruce head with contrast revealed significant swelling over the left Blvd, Rochester, New York 14623, USA (Flesher); VCA Oahu zygomatic arch. Multiple quills were removed from the tongue, Veterinary Specialty Center, 98–1254 Kaahumanu St. Ste. 151, oral mucosa, and periocular regions. During anesthesia it was Pearl City, Hawai 96782, USA (Lam); Department of Anatomic noted that the oxygen saturation decreased and the anesthetist Pathology, The Animal Medical Center, 510 East 62nd Street, reported that manual ventilation using the reservoir bag was New York, New York 10065, USA (Donovan). difficult. Upon auscultation, decreased bronchovesicular sounds Address all correspondence to Dr. Nathaniel Lam; e-mail: were heard on both sides of the thorax. Thoracic radiographs [email protected] confirmed bilateral pneumothorax and thoracocentesis of the Use of this article is limited to a single copy for personal study. left hemithorax yielded approximately 350 mL of air. A thoracic Anyone interested in obtaining reprints should contact the CT scan was performed and identified a bilateral pneumothorax CVMA office ([email protected]) for additional with bullae and evidence of foreign material in the left pulmo- copies or permission to use this material elsewhere. nary parenchyma.

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Due to concern for tension pneumothorax, a thoracostomy q12h, with methadone (Mylan Institutional), 0.2 mg/kg BW, IV, tube was placed and aspirated intermittently while the dog was q8h. Two days after surgery the dog had normal vital parameters, prepared for surgery. A sternal thoracotomy was performed was eating well, and was eupneic. The chest tubes were removed immediately thereafter to identify the cause of the pneumotho- 48 h after surgery prior to discharging the patient. rax. Multiple porcupine quills were embedded within the lung Six days after discharge the dog was presented to AMC parenchyma of the left cranial (cranial and caudal portions), Emergency Service when the owner noticed decreased activity REPORT CASE right middle and right caudal lung lobes. An additional quill and inappetance for the duration of 1 d, increased respiratory was discovered penetrating the mediastinum in the vicinity rate, and twitching of the ears. On physical examination, the of the aorta. These and all other visible quills were carefully dog had a normal temperature, heart rate, and respiratory rate dissected and removed. Partial lung lobectomies of the cranial with normal to increased bronchovesicular sounds in all lung and caudal portions of the left cranial lobe as well as the right fields. All cranial nerves were within normal limits, conscious caudal lung lobe were required to repair the damaged and leak- proprioception was present in all 4 limbs and all reflexes were ing parenchyma. An insufflation test under saline showed no intact. The dog had severe cervical pain on gentle palpation and leakage; however, all lung lobes had some degree of emphysema had a hunched posture with neck guarding and visible muscle and blebs. Due to concern that continued migration of unde- fasciculations over the dorsal aspect of the neck. Oxymorphone tected porcupine quills may further damage pleural parenchyma (DSM Pharmaceuticals, Greenville, North Carolina, USA), allowing pneumothorax to recur, it was elected to omental- 0.1 mg/kg BW, IV, was administered once. Thoracic radio- ize the damaged pleura in the thorax. A cranial abdominal graphs revealed mild pleural effusion and mild but clinically incision was performed. Two porcupine quills were detected insignificant pneumothorax. A magnetic resonance imaging within the omentum proper and were subsequently removed. (MRI) scan of the cervical region identified multiple soft tissue Electrocautery was used to transect the bursal portion of the linear hyperintensities on dorsal short tau inversion recovery greater omentum at its attachment at the greater curvature of the (STIR) images within the soft tissues of the neck, consistent stomach. The superficial and deep leaf were unfolded thereby with suspected migrated porcupine quills. Irregular thickened increasing the overall length of the omentum. Electrocautery was areas of contrast enhancement localized to the cervical meninges then used to make a 3.5 cm transverse incision in the ventral were noted. A cerebrospinal fluid (CSF) sample was collected diaphragm. The omentum was pulled through this incision, for culture and analysis. Cytology of the CSF revealed hemodi- which was just large enough for the omentum to pass through. lution with a neutrophilic pleocytosis, thus subdural empyema It was elected not to place suture material to close this incision was suspected. The dog was administered a fentanyl, lidocaine, because there was concern that strangulation of the omentum ketamine CRI for analgesia. The CRI consisted of fentanyl may occur. The omentum was not tacked to the tissues in the (Hospira, Lake Forest, Illinois, USA) at a rate of 2.8 mg/kg BW thorax but was wrapped carefully around the lung lobes and per hour, ketamine (Henry Schein Animal Health, Dublin, the mediastinum. The saline leak test was repeated and again Ohio, USA) at a rate of 0.2 mg/kg BW per hour, and lidocaine found to be negative. Bilateral 12F thoracostomy tubes (Teleflex (Hospira) at a rate of 25 mg/kg BW per minute. In addition, Medical, Research Triangle Park, North Carolina, USA) were dolasetron (Anzemet; Sanofi-Aventis, Bridgewater, New Jersey, placed and secured with a fingertrap pattern using 3-0 nylon USA), 0.6 mg/kg BW, IV, q24h, and pantoprazole (Novaplus, suture material. The sternebrae were re-apposed with 18-gauge Philadelphia, Pennsylvania, USA), 1 mg/kg BW, IV, q24h, orthopedic wire in an alternating interrupted and cruciate were administered to treat nausea and the dog was maintained pattern. The linea alba was closed using 0-polydioxanone on crystalloid fluids, 66 mL/kg BW per day with 7.5 mEq suture and the subcutaneous tissues were closed with 2-0 poly potassium chloride/250 mL. A culture of one of the previously diaxanone using a continuous subcutaneous suture pattern. The excised porcupine quills was positive for Candida and flucon- intradermal layers were closed using 3-0 poliglecaprone-25 in a azole (Teva Pharmaceuticals, Sellersville, Pennsylvania, USA), continuous subcuticular suture pattern. 4.5 mg/kg BW, IV, q12h, was administered. Metronidazole The patient was monitored with continuous electrocardiogra- (Teva Pharmaceuticals), 16 mg/kg BW, IV, q12h and cefotaxime phy and pulse oximetry. The pneumothorax was resolved at the (West-Ward), 52 mg/kg BW, IV, q8h, were initiated to address time of surgery and the chest tubes were aspirated every 4 h to potential bacterial infection. Gabapentin (Alkem Labs, Mumbai, ensure negative pressure during the post-operative period. The India), 1.8 mg/kg BW, PO, q8h, was administered to address patient was placed on enrofloxacin (Bayer, Shawnee Mission, discomfort. The dog was not being treated with non-steroidal Kansas, USA), 10 mg/kg BW, PO, q24h, ampicillin-sulbactam anti-inflammatory medications and so methylprednisolone (Pfizer), 22 mg/kg BW, IV, q8h, and triple antibiotic ophthalmic sodium succinate (Solumedrol; Pfizer), 28 mg/kg BW, IV, ointment (1/3 of a strip, q8h, OS) to provide broad-spectrum was administered to control potential inflammation. When antibiotic coverage of potential infection caused by porcupine pain was noted to be well-controlled, the lidocaine-ketamine quill migration. The patient was also started on maropitant CRI was discontinued and the dog was transitioned off fen- citrate (Pfizer), 1 mg/kg BW, SQ, q24h, and famotidine (Major tanyl to buprenorphine (Par Pharmaceutical, Spring Valley, Pharmaceuticals, Vonia, Michigan, USA), 0.5 mg/kg BW, IV, New York, USA), 0.01 mg/kg BW, PO, q6h. An amino acid q12h, to treat postoperative nausea. Analgesia was provided by supplemented crystalloid fluid (Procalamine; Braun, Irvine, a fentanyl, lidocaine, ketamine continuous rate infusion (CRI) California, USA), 50 mL/h was administered intravenously for 16 h after surgery and carprofen (Pfizer), 2 mg/kg BW, SC, to provide 60% of full resting energy requirement (RER).

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Figure 1. Gross postmortem findings in a 5-year-old spayed female Boston terrier mixed breed dog with disseminated porcupine quill migration. A — Heart. The right ventricle is opened (bottom) and the right ventricular outflow tract is visualized. Two quills are present. One quill penetrates into the lumen of the pulmonary artery (large arrow) with regional hemorrhage, and another quill disrupts and detaches the pulmonic valve (small arrow). B — Vertebral canal. A quill extends into the vertebral canal at the level of the C4/C5 intervertebral disk space (arrow). Bar = 6 mm. C — Skull and brain, ventral aspect. A porcupine quill is observed at the foramen magnum and base of the brain stem (large arrow). A focus of hemorrhage is present at the left ventral aspect of the brain stem (small arrow). Bar = 1 cm. D — Trachea. Two quills are embedded in the trachea (arrows). Bar = 1 cm. E — Kidney. A porcupine quill penetrates the cortex and extends into the medulla of the right kidney (large arrow). The point of another quill can be observed in the medulla (small arrow). Bar = 5 mm.

Blood analysis revealed a mild non-regenerative anemia, mild metronidazole (Teva Pharmaceuticals), 15 mg/kg BW, PO, thrombocytopenia, moderate leukocytosis with an unremark- q12h, gabapentin (Alkem Labs), 17.5 mg/kg BW, PO, q8h, able chemistry panel. The dog was discharged 4 d after her codeine (Roxane Labs), 1 mg/kg BW, PO, q6h, omeprazole second admission to hospital with prednisone (Roxane Labs, (Novaplus), 1.2 mg/kg BW, PO, q24h, and a fentanyl (Hospira), Columbus, Ohio, USA), 0.5 mg/kg BW, PO, q12h, cefpo- 25 mg/h, dermal patch. doxime (Sandoz, Kundl, Austria), 5.8 mg/kg BW, PO, q12h, Four weeks after its original presentation at AMC the patient fluconazole (Teva Pharmaceuticals), 4.5 mg/kg BW, PO, q12h, greeted the owner at the door and died acutely soon thereafter.

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Necropsy revealed disseminated quill migration. A chronic porcupine quills are left in place. Any porcupine quills found at thrombus in the left ventricle contained an embedded quill, the surface of tissues that are visible should always be extracted. with regional myodegeneration, myocarditis, and replacement Medical management is beneficial when surgical excision of fibrosis. Two quills were found within the pulmonary artery and quills is considered too risky or when the patient is a poor right ventricular outflow tract, causing significant pulmonary surgical candidate. However, failing to remove quills increases valvular damage (Figure 1A), regional pancarditis and fibropla- the risk of further migration and necessitates management of REPORT CASE sia. A porcupine quill penetrated the 4th cervical vertebral body clinical symptoms. The goals of medical treatment should be and was found within the vertebral canal between the 4th and to address localized pain and irritation secondary to physical 5th cervical vertebrae (Figure 1B) with secondary cervical spinal irritation and foreign body reactions, infection of tissues in the cord trauma. A quill was found at the brainstem (Figure 1C) form of draining tracts, and quill migration-causing trauma to with concurrent leptomeningeal hemorrhage, hemosiderosis, and joints and vital organs (2). fibrosis. Twelve quills were observed in the soft tissues of the left Quills are frequently contaminated and may be responsible and right head, including the left mandible, base of the tongue, for both septic and sterile foreign body reactions. A unique left temporal muscle, and periocular regions. There were mul- finding in this case was that a culture obtained from the quills tifocal quills within the left larynx, perilaryngeal muscles, left removed during the initial surgery was positive for Candida oropharynx, around and within the tracheal wall (Figure 1D), but no bacteria were isolated. Antimicrobial medications were adjacent to and within the adventitia of the esophagus, in administered before acquiring the culture sample and may the root of the mesentery, right thoracic epaxial muscles, and have contributed to the failure to detect aerobic and anaerobic 3 quills were embedded within the cortex and medulla of the microbes. right kidney (Figure 1E). Chronic inflammation, pleuritis, and Surgical management may be advantageous when porcupine thrombosis were observed throughout the lungs. No porcupine quills can be removed without risk of causing additional trauma quills were evident in the lung tissue at the time of post-mortem to surrounding structures. Surgical treatment provides exposure examination. The site of omentalization was intact with fibrous and visualization of damaged tissue in addition to removing the adhesions to the ventral aspect of the left cranial, caudal, right cause of irritation and preventing future migration of quills. cranial, and middle lung lobes, mediastinum and pericardium. In this dog, surgical intervention allowed for direct removal of porcupine quills and repair of tissues damaged by migration Discussion tracts. However, as in this case, all migrating quills may not be Porcupine quill injuries in dogs are common in regions of North located and removed despite surgical intervention. Moreover, America (1) especially during the spring and fall when porcupine surgical extrication of porcupine quills is costly and may have activity is increased (2). Since many quill injuries begin with an increased risk of morbidity or mortality if the quills are dogs engaging a porcupine, wound locations like those seen in embedded in vital or delicate structures and are difficult to this case include the external head, oral cavity, gingiva, mouth, dissect or remove. nose, neck region, and less frequently, the limbs and truncal Surgical treatment of lung parenchymal damage secondary region (2,3). Quills may break off at the surface of the skin and to porcupine quill migration was performed concurrently with remain lodged there or migrate deeper into the tissues where omentalization of the thorax that involved mobilization of the they increase risk of infection and damage to vital structures omentum through a diaphragmatic incision (9). There was con- and organs (4,5). Quills become increasingly rigid and brittle cern that additional porcupine quills undetected during surgery the longer the quills remain in tissue, thus treatment is likely had future migration potential and the authors hoped that the more successful if they are removed soon after injury (2). In a omentum would adhere at future sites of pleural inflammation comprehensive study of generalized quill injuries from 1998 and irritation. The definitive effect of this omentalization is to 2002, it was reported that time from injury to treatment unknown. Potential limitations of the omentalization technique was negatively correlated with morbidity and survival (2). The include a slight increase in surgical time and the possibility of time from injury to treatment was more significant than the bacterial translocation between thoracic and abdominal com- number of quills sustained during injury and the antimicrobials partments. In this case, no sutures were used to close the incision selected to treat the injury. Of 296 visits reported, complications in the diaphragm. Theoretically this may allow for migration were observed in 32 cases (10.8%) and included 1 case with a of the omentum or herniation of abdominal organs, although pneumothorax, 4 with peri-ocular complications (2), and quill this was not evident in this case. Further studies evaluating migration resulting in injuries to the pulmonary parenchyma, omentalization are indicated. spinal cord, cardiovascular, and neurologic structures (6–8). The Medical management was initially pursued in this case when dog herein suffered damage to multiple vital structures due to the dog was re-presented after remaining quills migrated to the porcupine quill migration and was treated both medically and spinal cord resulting in secondary meningitis and empyema. In surgically before succumbing to these injuries. retrospect, surgical management at this point would have been Selection of surgical intervention versus medical manage- more beneficial. Despite the risks of surgical intervention in ment when treating porcupine quill migration in the dog may close proximity to critical structures and the success achieved be contingent on proximity of the quills to vital structures. with medical management initially, secondary complications Damage to tissues that would be caused by surgical extraction from our inability to remove the inciting cause resulted in fatal must be weighed against damage from further migration if complications.

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Porcupine quills remain elusive with use of current imaging contrast enhancement is indicative of inflammatory response techniques and modalities. Diagnosis and detection of individual characterized by edema and hemorrhage secondary to trau- quills proves to be difficult and has not yet been widely studied. matic migration. Magnetic resonance imaging and CT may be Improved imaging techniques and specific quill localization of diagnostic value, but further research is required to refine expertise for the purposes of surgical excision are needed. interpretation. Porcupine quills are typically not visible on radiographs (3). This case report highlights multiple porcupine migration Sonographically, porcupine quills have echogenic walls, a fluid- injuries with a continuum of surgical and medical treatment, filled anechoic lumen, a tapering point, and appear as 2 distinct which may be considered for treatment of future cases. This parallel hyperechoic lines that converge at the point of the quill report also highlights the necessity for further study of imaging when the quill is parallel to the transducer (3). Difficulty can modalities with improved sensitivity and specificity to detect arise when the porcupine quill is transverse to the transducer as porcupine quills. CVJ RAPPORTCAS DE images can be easily misinterpreted as small blood vessels and appear as small hyperechoic tubular structures (7). Previous References studies have documented the effectiveness of ultrasound for 1. Kavanagh J. Nature Alberta: An Illustrated Guide to Common Plants detection of quills in the eye, humeroradial joint, and flexor and Animals. Edmonton, Alberta: Lone Pine Publ, 1991:29. 2. Johnson MD, Magnusson KD, Shmon CL, Waldner C. Porcupine quill tendon (3,5,7). Ultrasonography may have been a useful modal- injuries in dogs: A retrospective of 296 cases (1998–2002). Can Vet J ity to consider in this case. 2012;47:677–682. Although pulmonary migration was suspected in the present 3. Grahn BH, Szentimrey D, Pharr JW, Waldner C. Ocular and orbital porcupine quills in the dog: A review and case series. Can Vet J 1995; case, both MRI and CT were ineffective at demonstrating por- 36:488–493. cupine quills directly and could only detect migration tracts. Use 4. Wobeser G. Traumatic, degenerative, and developmental lesions in wolves of MRI and CT in the detection of porcupine quill migration and coyotes from Saskatchewan. J Wildl Dis 1992;28:268–275. 5. Brisson BA, Bersenas A, Etue SM. Ultrasonographic diagnosis of septic has been rarely reported. In 1 case report, MRI images obtained arthritis secondary to porcupine quill migration in a dog. J Am Vet Med with a 1.0T MRI machine identified a circular well-demarcated Assoc 2004;224:1467–1470. T2-hypointense lesion confirmed to be a porcupine quill within 6. Daoust PY. Porcupine quill in the brain of a dog. Vet Rec 1991;199:1616. the vertebral canal of a young Gordon setter associated with 7. Sauve PS, Sereda NC, Sereda CW. Identification of an intra-cranial intra-axial porcupine quill foreign body with computed tomography in an arachnoid diverticulum (8). In another case report, CT a canine patient. Can Vet J 2012;52:187–189. was used to diagnose an intra-cranial axially located porcupine 8. Schneider AR, Chen AV, Tucker RL. Imaging diagnosis — Vertebral canal quill. Porcupine quills on the CT in this patient appeared as porcupine quill with presumptive secondary arachnoid diverticulum. Vet Radiol Ultrasound 2010;51:152–154. hyperdense linear structures with post-contrast enhancement of 9. Tobias KM, Johnson SA. Veterinary Surgery: Small Animal. Vol 2. the parenchyma surrounding the quill (7). The peri-quill post- St. Louis, Missouri: Elsevier Saunders, 2012;50:1484–1806.

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284 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY Case Report Rapport de cas

Necrotizing hepatitis associated with Clostridium novyi in a pony in western Canada

Jennifer L. Davies, Francesco A. Uzal, Ashley E. Whitehead

Abstract — Severe icterus, peritoneal effusion, localized fibrinous peritonitis, and necrotizing hepatitis were found at necropsy of a 20-year-old female pony with a history of acute onset depression, inappetence, fever, and marked elevation in hepatic enzymes. Gross pathology, histopathology, and immunohistochemistry were compatible with a diagnosis of clostridial hepatitis caused by Clostridium novyi-group bacteria. This is believed to be the first reported case of clostridial hepatitis in an equid in Canada, and only the third report of this rare disease in North America.

Résumé — Hépatite nécrosante associée à Clostridium novyi chez un poney de l’Ouest canadien. Un ictère grave, une effusion péritonéale, une péritonite fibrineuse localisée et une hépatite nécrosante ont été constatées chez un poney femelle âgé de 20 ans avec une anamnèse d’apparition soudaine de dépression, d’inappétence, de fièvre et d’élévations marquées des enzymes hépatiques. La pathologie clinique, l’histopathologie et l’immunohistochimie étaient compatibles avec un diagnostic d’hépatite clostridiale causée par une bactérie du groupe Clostridium novyi. On croit qu’il s’agit du premier cas signalé d’hépatite clostridiale chez un équidé au Canada et seulement le troisième rapport de cette maladie rare en Amérique du Nord. (Traduit par Isabelle Vallières) Can Vet J 2017;58:285–288 lostridial hepatitis is most commonly seen in small and those of bacillary hemoglobinuria (BH), the lesions associated C large ruminants (1,2). In ruminants, there are 2 clinical with hemolytic anemia, which are characteristic of BH, are syndromes caused by the Clostridium novyi group of bacteria; usually not seen in ruminants with infectious necrotic hepati- black disease (infectious necrotic hepatitis) caused by C. novyi tis, probably because the beta toxin gene is far less expressed in type B and bacillary hemoglobinuria caused by C. haemolyticum C. novyi type B than in C. haemolyticum. (also known as C. novyi type D) (3,4). There is considerable The pathogenesis of both diseases begins with the ingestion overlap in the gross pathology, histopathology, and pathogen- of environmental spores with seeding to histiocytes in the liver, esis of these diseases. Both diseases are characterized by acute spleen, bone marrow, and perhaps other organs. Spores lie hepatic necrosis and systemic lesions associated with toxemia dormant in the liver until the formation of a localized anaero- and generalized vascular damage (3). As the name suggests, bic environment allowing for germination of spores and the bacillary hemoglobinuria is further characterized by intravas- production of potent exotoxins by vegetative bacteria. In rumi- cular hemolysis with anemia and hemoglobinuria attributed to nants, migration of the common liver fluke, Fasciola hepatica, the phospholipase activity of the beta toxin produced in large is thought to be the main initiating event (4). amounts by C. haemolyticum (3,4). Although gross changes in Clostridial hepatitis is rare in equids with only 7 cases in the sheep and cattle with infectious necrotic hepatitis are similar to veterinary literature (1–3,5–7). Cases have been reported in Australia, New Zealand, the United Kingdom, and the United States. To our knowledge, this is the first reported case of equine Diagnostic Services Unit (Davies) and Department of Veterinary clostridial hepatitis in Canada and only the third case in North Clinical and Diagnostic Sciences (Whitehead), University of America. Here we describe the clinicopathologic features of this Calgary Faculty of Veterinary Medicine, 11877 85th Street NW, rare entity including ultrasonographic findings that have not Calgary, Alberta T3R 1J3; California Animal Health and Food been thoroughly documented. Safety Laboratory, Faculty of Veterinary Medicine, University of California–Davis, 105 West Central Avenue, San Bernardino, Case description California 92408, USA (Uzal). A 20-year-old, female pony was presented with a history of Address all correspondence to Dr. Ashley Whitehead; e-mail: acute onset of depression, decreased appetite, and separation [email protected] from herdmates. On presentation, the pony was tachycardic, Use of this article is limited to a single copy for personal study. tachypneic, and mildly febrile (38.6°C). Initial blood analysis Anyone interested in obtaining reprints should contact the consisting of a complete blood (cell) count (CBC) and serum CVMA office ([email protected]) for additional biochemical profile, including liver parameters, were unremark- copies or permission to use this material elsewhere. able [aspartate aminotransferase (AST); 491 IU/L, reference

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Figure 2. Ultrasound image of the liver of the pony obtained in the right 12th intercostal space. Note the increased number of Figure 1. Ultrasound image of the liver of the pony obtained in multifocal hyperechoic foci deep within the hepatic parenchyma. the left 9th intercostal space. This image shows an increased The left side of the image is dorsal and the right side is ventral. echogenicity of the hepatic tissue with multifocal hyperechoic foci. Subcapsular and intraparenchymal gas are present. The spleen is overlying the liver. The left side of the image is dorsal and the right side is ventral. at twice maintenance (100 mL/kg BW, IV per day) and antibiotic therapy consisting of sodium penicillin G (Pharmaceutical interval (RI): 180 to 570 IU/L], total bilirubin (35 mmol/L, Partners of Canada, Richmond Hill, Ontario), 22 000 IU/kg RI: 33 to 63 mmol/L), alkaline phosphatase (ALP; 226 IU/L, BW, IV, q6h and gentamicin (Gentocin; Merck Animal Health, RI: 73 to 327 IU/L), and gamma glutamyl transferase (GGT; Kirkland, Quebec), 6.6 mg/kg BW, IV, q24h. Flunixin meglu- 28 IU/L, RI: 5 to 30 IU/L). The mare was initially treated with mine at 1.1 mg/kg BW, IV, q12h was also administered. The oral electrolytes and water via nasogastric intubation. Flunixin pony was depressed but did not show any other neurological meglumine (Flunixin injection; Zoetis Canada, Kirkland, signs and continued to eat small amounts of hay and concen- Quebec), 0.5 mg/kg body weight (BW), IV, was administered trate. The pony continued to deteriorate over the next 24 h, to aid in controlling the mild pyrexia. An impending colitis was showing signs of systemic inflammatory response syndrome initially suspected by the admitting veterinarian. (SIRS) and abdominal pain. Further diagnostic and treatment Over a 2-day period, the pony deteriorated with devel- options were discussed with the owner; however, euthanasia fol- opment of a high fever (39.6°C) and marked icterus. A lowed by necropsy was elected due to the mare’s poor response CBC performed at this time revealed a mild monocytosis to medical therapy and declining systemic condition. (0.73 3 109/L, RI: 0.20 to 0.60 3 109/L) and mild thrombo- At necropsy, the body was fresh, in good nutritional condi- cytopenia (83 3 103/mL, RI: 100 to 250 3 103/mL). Marked tion, and there was no evidence of dehydration. There was severe increases in sorbitol dehydrogenase (SDH) (. 150.0 IU/L, RI: icterus. Within the peritoneal cavity there were approximately 1.9 to 5.8 IU/L), aspartate aminotransferase (AST; 1817 IU/L, 15 L of opaque, reddish fluid. There were numerous petechiae RI: 180 to 570 IU/L), total bilirubin (286.3 mmol/L, RI: and ecchymoses on the small intestinal serosa. Visible from 33 to 63 mmol/L) and moderate increases in alkaline phospha- both the visceral and diaphragmatic surfaces of the left liver tase (ALP) (415 IU/L, RI: 73 to 327 IU/L), alanine aminotrans- lobe, there was an extensive, moderately well-defined, approxi- ferase (ALT) (62 IU/L, RI: 5 to 30 IU/L), and gamma glutamyl mately 35 cm in diameter focus where the parenchyma was transferase (GGT) (55 IU/L, RI: 5 to 30 IU/L) were noted on elevated, firm, and dark red to tan. This area was covered by a serum biochemical profile. Bile acids were within normal limits thick layer of fibrin on the capsular surface with adhesion to (10.2 mmol/L, RI: 0 to 19 mmol/L). Red-colored urine was the diaphragm and spleen (Figure 3). On section, there were collected which was 41 positive for hemoglobin on urinalysis extensive, malodorous areas of necrosis and hemorrhage that dip stick and no intact red blood cells were noted on cytology were accompanied by emphysema. Thrombi were observed following sedimentation. Transcutaneous abdominal ultrasound within blood vessels (Figure 4). was performed using a 1.9 MHz convex probe. Multifocal, Sections of liver, spleen, lung, kidney, adrenal gland, thyroid hyperechoic foci (# 1 cm diameter) were identified within the gland, pancreas, heart, stomach, small intestine, large intestine left aspect of the liver parenchyma (Figure 1). Larger subcapsular and brain were fixed in 10% buffered formalin for 24 h, pro- hyperechoic areas were associated with reverberation artifact cessed routinely for histological examination, and stained with consistent with gas. The right aspect of the liver had fewer, hematoxylin and eosin (H&E). Gram stain was used on selected smaller hyperechoic foci deep in the parenchyma (Figure 2). sections of liver. Fresh specimens of liver were submitted for The small intestines were within normal limits for size and aerobic and anaerobic culture and fluorescent antibody testing wall thickness with minimal motility. There were pockets of (FAT) for C. novyi, C. sordellii, C. chauvoei, and C. septicum. hypoechoic free abdominal fluid in the left abdomen. For immunohistochemistry, formalin-fixed, paraffin-embedded During this time, the mare was administered Lactated 4 mm thick sections of liver were processed by a streptavidin- Ringer’s Solution (Baxter Corporation, Mississauga, Ontario) biotin technique for C. novyi, C. sordellii, C. septicum, and

286 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 5. Immunohistochemical staining of a section of liver for Clostridium novyi. Large numbers of strongly positive staining rods are present within an area of hepatic necrosis. Figure 3. Diaphragmatic surface of the liver of the pony. Bar = 50 mm. Stain: rabbit polyclonal anti-C. novyi antibodies Involving the left liver lobe, there is an extensive, moderately (Veterinary Medical Research and Development, Pullman, well-defined, approximately 35 cm focus where the parenchyma Washington, USA). is swollen, firm, and dark red to tan. This area was accompanied by a thick layer of fibrin coating the capsular surface.

were variable numbers of large (6 mm 3 1 mm), Gram-positive rods compatible with Clostridium species. There was no evidence of hemoglobinuric nephrosis in the sections of kidney examined. Diffuse splenic congestion was a feature and the splenic capsule was lined by a layer of fibrin and degenerate neutrophils. Fluorescent antibody testing on sections of fresh liver was negative for C. novyi, C. sordellii, C. chauveoi, and C. septicum. No bacterial pathogens were isolated on aerobic or anaerobic culture of liver. Bacteria in formalin-fixed, paraffin-embedded sections of liver demonstrated strongly positive immunohistochemical staining for C. novyi (Figure 5) and were negative for C. sordellii, C. chauveoi, and C. septicum. Discussion Figure 4. Cut surface of the liver of the pony. There are multifocal to extensive, well-demarcated, tan to dark red, dry, Gross pathology, histopathology, and immunohistochemistry in dull foci consistent with coagulation necrosis. Necrosis is this case were consistent with a diagnosis of clostridial hepatitis accompanied by hemorrhage and emphysema. Blood vessels caused by C. novyi-group bacteria. Clostridial hepatitis is a com- contain thrombi (arrow). mon disease of ruminants, and a rare disease of equids. To date, there are 7 reported cases of clostridial hepatitis C. chauvoei using the Dako EnVision kit (Dako, Carpenteria, in equids occurring in Australia, New Zealand, the United California, USA) according to the manufacturer’s instruc- Kingdom, and the United States (1–3,5,6). Similar to the cur- tions. Rabbit polyclonal anti-C. novyi, anti-C. sordellii, anti- rent case, clinical disease in horses described before was char- C. septicum, and anti-C. chauveoi antibodies (Veterinary Medical acterized by acute onset of depression, fever, abdominal pain, Research and Development, Pullman, Washington, USA) were icterus, tachycardia, and tachypnea with rapid deterioration and used. Negative controls consisted of sections incubated with death in 12 to 48 h (2,7). To date, successful therapy has not normal rabbit serum instead of the primary antibody. Positive been described; this is not surprising given the peracute nature controls consisted of sections of liver or muscle known to con- of the disease, rapid development of toxemia, and difficulty in tain the clostridial species investigated. establishing an antemortem diagnosis. Reported necropsy find- Microscopically, there were multifocal to coalescent zones of ings include serosanguinous pericardial, pleural and peritoneal acute coagulation necrosis bordered by an intense band of viable effusions, serosal hemorrhages, icterus, fibrinous peritonitis, and degenerate neutrophils. Areas of emphysema frequently and hepatic necrosis (1,2,6,7). Interestingly, the hepatic necro- accompanied the necrosis. The tunica media of blood vessels was sis is frequently described as being restricted to the left side of disrupted by fibrinoid change, nuclear debris, neutrophils, and red the liver (1,2,6,7) as was observed in this pony. The reason for blood cells consistent with vasculitis. Affected blood vessels often this seemingly unique distribution within the liver remains contained thrombi. Within the zone of coagulation necrosis there unknown.

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Key to the pathogenesis of clostridial hepatitis is the devel- to further discriminate to the species level. Although red urine opment of anaerobic conditions in the liver favoring spore ger- was reported in the clinical history, there was no evidence of mination. In ruminants, spore germination is most frequently hemolysis on CBC nor was there evidence of hemoglobinuric associated with liver fluke migration. The inciting cause of the nephrosis on histopathology and the bladder was devoid of suitable anaerobic conditions for spore germination within the urine at necropsy. The lack of clear evidence for intravascular equine liver has not been definitively determined. Strongyle spp. hemolysis in this case may make it more comparable to infec- migration though the liver has been proposed as an initiating tious necrotic hepatitis caused by C. novyi rather than bacil- cause, but has been inconsistently reported (3,5). In the cur- lary hemoglobinuria caused by C. haemolyticum. The ongoing rent case, there was no evidence of larval migration on gross advancement of molecular diagnostic techniques will hopefully or microscopic examination of the liver. Interestingly, many allow for discrimination between these organisms in the future. of the reported cases have a recent history of anthelminthic In conclusion, this appears to be the first reported case of RAPPORTCAS DE therapy prior to the onset of clinical signs (1,3,7) suggesting the clostridial hepatitis in an equid in Canada and only the third possibility of liver damage following destruction of migrating report of this disease in North America. While clostridial parasites. Recent use of anthelminthics was not reported in the hepatitis appears to be a rare disease of horses, it should still be current case. considered as a differential diagnosis for acute hepatic disease in Arriving at an etiologic diagnosis was problematic in this case. this species. The ability to rapidly recognize the clinical features Liver was submitted to 2 laboratories for anaerobic culture and of this acute, fulminating disease in horses will be crucial to FAT for Clostridium spp. Clostridium novyi-group organisms future successful therapy. CVJ were not detected by FAT or by culture, highlighting the chal- References lenge at arriving at an etiologic diagnosis in cases of clostridial 1. Gay CC, Lording PM, McNeil P, Richards WPC. Infectious necrotic hepatitis. Both C. novyi and C. haemolyticum are extremely hepatitis (black disease) in a horse. Equine Vet J 1980;12:26–27. oxygen sensitive and fastidious in their nutritional requirements 2. Sweeny HJ. Infectious necrotic hepatitis in a horse. Equine Vet J 1986; making culture challenging and an unreliable diagnostic tool (8). 18:150–151. 3. Oaks JL, Kanaly ST, Fisher TJ, Besser TE. Apparent Clostridium haemo- The reason for the negative FAT result is unknown, but may lyticum/Clostridium novyi infection and exotoxemia in two horses. J Vet reflect sampling as the organisms were not uniformly distributed Diagn Invest 1997;9:324–325. throughout the liver. In the current case, immunohistochemistry 4. Stalker MJ, Hayes MA. Liver and biliary system. In: Maxie MG, ed. Jubb, Kennedy and Palmer’s Pathology of Domestic Animals. 5th ed. Vol 2. was positive for C. novyi and was instrumental in confirming London, UK: Saunders Elsevier, 2007:354–356. the diagnosis of clostridial hepatitis. It is important to note that 5. Dumaresq JA. A case of black disease in a horse. Aust Vet J 1939;15: C. novyi type B and C. haemolyticum are very closely related and 53–57. 6. Hollingsworth TC, Green VJD. Focal necrotizing hepatitis caused by polyclonal antiserum made for either is typically cross-reactive Clostridium novyi in a horse. Aust Vet J 1978;54:48. and unable to differentiate between the 2 species (8). Similarly, 7. Whitfield LK, Cypher E, Gordon SJG, et al. Necrotic hepatitis asso- the generic C. novyi antibody used for immunohistochemis- ciated with Clostridium novyi infection (black disease) in a horse in New Zealand. N Z Vet J 2015;63:177–179. try in the current case cross-reacts with C. haemolyticum. As 8. Hatheway CL. Toxigenic clostridia. Clin Microbiol Rev 1990;3: a result, we were able to establish a diagnosis of clostridial 66–98. hepatitis caused by C. novyi-group bacteria, but were unable

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288 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY Case Report Rapport de cas

Treatment of chronic sinusitis in a horse with systemic and intra-sinus antimicrobials

Danielle L. Gordon, Catherine L. Radtke

Abstract — A 12-year-old Norwegian Fjord gelding was diagnosed with paranasal sinusitis as a post-operative complication of tooth repulsion surgery. The infection with inspissated purulent material persisted despite sinus trephination and lavage, and systemic antimicrobial therapy. Resolution occurred following infusion of a gelatin/ penicillin mixture into the right rostral and caudal maxillary sinus.

Résumé — Traitement de la sinusite chronique chez un cheval à l’aide d’antimicrobiens systémiques et dans les sinus. Une sinusite paranasale a été diagnostiquée chez un hongre Fjord âgé de 12 ans comme complication postopératoire d’une chirurgie pour la répulsion d’une dent. L’infection avec du matériel purulent épaissi a persisté malgré la trépanation et le lavage du sinus et une thérapie antimicrobienne systémique. La résorption s’est produite après l’infusion d’un mélange de gélatine et de pénicilline dans les sinus maxillaires rostral et caudal droits. (Traduit par Isabelle Vallières) Can Vet J 2017;58:289–292

Case description evidence of sinusitis or post-surgical complications. The patient was rechecked 1 mo after surgery to have the packing material 12-year-old Norwegian Fjord gelding was presented to the removed. At that time, the packing material appeared to be Atlantic Veterinary College (AVC) in September 2015 for A in place; however, it was not possible to remove it from the evaluation of post-surgical complications, including a 2-day alveolus. There was no evidence of post-operative complications; history of unilateral right mucopurulent nasal discharge. In therefore, the packing material was left in place. June 2015, the horse was presented to the AVC with a history Upon presentation to the AVC in September 2015, the of fractured maxillary cheek tooth 109 and associated periapical patient was quiet, but alert and responsive. His temperature, infection. The patient also had concurrent sinusitis; therefore, pulse, and respiration were all within normal limits. A firm facial tooth repulsion under general anesthesia was performed, as it swelling that persistently indented upon application of digital was the surgeon’s preference to explore and debride the affected pressure was evident in the region of the right rostral and caudal sinus at the time of tooth removal. A maxillary sinus flap was maxillary sinuses. The swelling was noted to be painful on palpa- created and part of the maxillary septum was removed. The tion. Malodorous mucopurulent unilateral right nasal discharge tooth was repulsed, the maxillary sinus was debrided, and was noted and serous ocular discharge was present in the right the alveolus was appropriately packed with methyl methac- eye. All other physical examination findings were unremarkable. rylate (Technovit 6019; Heraeus Kulzer GmbH, Wehrheim, Based on the patient’s history and presenting clinical signs, the Germany). The patient recovered well from surgery. The patient most likely differential diagnosis was paranasal sinusitis. was prescribed 10 d of trimethoprim-sulfamethoxazole (TMS) Further diagnostics included skull radiographs and a thor- (Apo-Sulfatrim DS; Apotex, Toronto, Ontario), 25 mg/kg ough oral examination. A fronto-maxillary radiographic projec- body weight (BW), PO, q12h, and the surgical site was flushed tion revealed a soft-tissue opacity in the entire right rostral and 3 times on consecutive days with 1.5 L of lactated Ringers caudal maxillary sinuses and moderate deviation of the nasal solution. The patient was discharged 4 d after surgery with no septum toward the left side. Latero-lateral views demonstrated fluid lines within the maxillary sinus. No fluid lines were Department of Health Management, Atlantic Veterinary noted in the concho-frontal sinus. The ventral conchal sinus College, University of Prince Edward Island, 550 University could not be distinguished on the radiographs; therefore, its Avenue, Charlottetown, Prince Edward Island C1A 4P3. involvement at that time was unknown. Radiographic findings Address all correspondence to Dr. Danielle Gordon; e-mail: were consistent with the presumptive diagnosis of sinusitis. [email protected] The patient was subsequently sedated in order to perform an Use of this article is limited to a single copy for personal study. oral examination. The ventral aspect of the packing material Anyone interested in obtaining reprints should contact the was evaluated and determined to be intact and appropriately CVMA office ([email protected]) for additional positioned, and the remainder of the oral examination revealed copies or permission to use this material elsewhere. no abnormal findings.

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Figure 1. Endoscopic view of the right maxillary sinus, which Figure 2. Endoscopic view of the right maxillary sinus following revealed inspissated purulent material and inflamed mucosa. the first instillation of the gelatin/penicillin mixture.

Trephination and sinoscopy were done to further evalu- to increase the pressure of the lavage solution in an attempt to ate the right rostral and caudal maxillary sinuses. A 1/2-inch disrupt the inspissated material. However, the increased pressure (13 mm) Galt trephine was used to penetrate the bone of of the lavage solution directed at areas of inspissated material the right maxillary sinus at a location 4 cm rostral and 2 cm did not result in disruption of the exudate. The procedure was ventral to the medial canthus of the eye. Trephination revealed repeated the following day and once again, minimal improve- thickening of the maxillary bone and resulted in entry into ment was noted as a significant amount of purulent and inspis- the rostral maxillary sinus. Previous partial removal of the sated material was still present. maxillary septum allowed for concurrent evaluation of the Culture results revealed moderate growth of Trueperella rostral and caudal maxillary sinuses. A flexible 9.8-mm video pyogenes. This bacterium has a slow rate of growth; therefore, endoscope (EG-2990i Video Gastroscope; Pentax, Mississauga, susceptibility testing was not performed as the results would Ontario) was introduced into the right rostral and caudal not have been valid. Anaerobic culture was not performed, maxillary sinuses and revealed hyperemic respiratory epithe- but it was assumed that anaerobic bacteria were present within lium and approximately 200 mL of purulent and inspissated the sinus due to the presence of T. pyogenes. A 50-mL gelatin/ purulent material (Figure 1). The caudal and rostral portions penicillin solution, for use in guttural pouch empyema, was of the maxillary sinus were flushed transendoscopically with then prepared as reported by Verheyen et al (1) and infused into 1.5 L of sterile saline, which allowed for drainage of purulent the patient’s right rostral and caudal maxillary sinuses (1). The exudate. A sample of the purulent material was collected for solution was prepared by combining 2 g of gelatin (household routine culture and sensitivity, and the sinus was flushed again grade) with 40 mL of sterile water. The solution was heated in with 1.5 L of sterile saline. The inspissated purulent material the microwave for approximately 20 s to dissolve the gelatin. inhibited visualization and insertion of the endoscope through The solution was cooled to 45°C to 50°C. A sodium penicil- the conchomaxillary aperture, which consequently prevented lin solution was prepared by adding 10 mL of sterile water to evaluation of the ventral conchal sinus. The dorsal aspect of the 10 000 000 units of sodium benzyl penicillin G (Penicillin G; methyl methacrylate alveolar packing material was visualized. Pharmaceutical Partners of Canada, Richmond Hill, Ontario) It appeared to be intact, but complete healing with granula- and mixed with the cooled gelatin. The solution was dispensed tion tissue had not occurred. There was no evidence of feed into 2 syringes and placed in the refrigerator at 4°C overnight to material within the maxillary sinus. In the surgeon’s experi- set. Sinus lavage was performed before instillation of the gelatin/ ence, the packing material can be left in place for extended penicillin mixture into the right rostral and caudal maxillary periods of time without causing secondary sinusitis. Therefore, sinuses. Sinoscopy and sinus lavage was performed 2 days fol- to prevent the creation of an oromaxillary fistula, the packing lowing the infusion and revealed a dramatic improvement. The material was not removed. A 10-day course of TMS (Apotex), mucosa appeared to be less inflamed and the purulent discharge 25 mg/kg BW, PO, q12h, was initiated, as well as a 3-day was markedly reduced compared to the previous sinoscopy course of phenylbutazone (Phenylbutazone Tablets; Dominion (Figure 2). Another gelatin/penicillin mixture was instilled into Veterinary Laboratories, Winnipeg, Manitoba), 2.2 mg/kg BW, the right rostral and caudal maxillary sinuses and 2 days later PO, q12h. sinoscopy revealed significant improvement in that the mucosa The subsequent day sinoscopy revealed that a significant appeared normal and there was no purulent exudate present. A amount of purulent and inspissated material persisted within the final sinus lavage and infusion of the gelatin/penicillin mixture maxillary sinus and little improvement had occurred from the into the right maxillary sinus was done and the patient was dis- previous day. Transendoscopic sinus lavage was performed with charged. At 6 mo after infusion of the gelatin/penicillin mixture, approximately 6 L of sterile saline. A fluid rate of 300 mL/min the patient continued to do well at home with no evidence of through the 2.8 mm insertion tube of the endoscope was used recurrent sinusitis.

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Discussion Since there was no evidence of an orosinusoidal fistula or another underlying disease on presentation, this horse was The case described in this report emphasizes complications routinely treated for sinusitis, which as previously mentioned, and challenges that can be encountered during the treatment typically relies on antimicrobial therapy and copious lavage of of secondary sinusitis due to tooth repulsion surgery. Therapy, the affected sinus(es) (3,9). Aerobic culture results in this case which typically involves sinus lavage and appropriate antimicro- showed moderate growth of Trueperella pyogenes, which to the REPORT CASE bial therapy, is not always effective at eliminating the infection; authors’ knowledge, has not been reported as an isolate in equine therefore, additional therapy may be warranted in complicated sinusitis cases. However, T. pyogenes is ubiquitous, a commensal cases. This case report describes the addition of a gelatin/ organism in the mucosa of the upper respiratory tract of ani- penicillin mixture into the maxillary sinus as an unprecedented mals, and an opportunistic bacterium that is often associated adjunct therapy for cases of chronic sinusitis. with pyogenic infections. Therefore, isolation of T. pyogenes Equine sinonasal disease occurs infrequently; however, it is a in this case was not surprising (15,16). Since T. pyogenes is an clinically significant disease due to difficulties in treatment and opportunistic bacterium, it often contributes to disease as a the chronic nature of the disease (2). Sinusitis is the most com- secondary invader to another bacterial infection, which often mon disease that affects the paranasal sinuses, and it is classified includes anaerobic bacteria (15,16). Consequently, a mixed as either primary or secondary and acute or chronic (2). Primary bacterial infection with an anaerobic component was assumed sinusitis usually results from a previous upper respiratory tract to be present in this case. The assumption of a multispecies infection, whereas secondary sinusitis occurs as a consequence infection was based on characteristics of sinusitis caused by a of another disease process (3,4). Causes of secondary sinusitis tooth root infection, which in this case, was most likely due to include dental disease, facial trauma, maxillary cysts, ethmoid residual exudate from the horse’s previous periapical infection hematomas, sinonasal neoplasia, and post-operative complica- (3,7). Trueperella pyogenes is consistently susceptible to penicil- tion of tooth repulsion surgery (3,4). lin and has a high rate of resistance against TMS (15). Obligate Paranasal sinusitis, especially cases of secondary or chronic anaerobic bacteria are also generally susceptible to penicillin; disease, can be difficult to treat, as it depends on the cause of the therefore, addition of penicillin to the treatment regimen was disease, as well as the bacteria involved (5). The most common appropriate in this case (15). In addition, local delivery of the bacterial isolates in cases of primary sinusitis are Streptococcus penicillin was considered to be the most appropriate route of equi and Streptococcus zooepidemicus (5,6), whereas culture of administration, as it would allow for antimicrobial action at the secondary sinusitis samples generally yields a mixed bacterial site of infection. population, including anaerobes (7,8). Treatment of primary Topical antimicrobial therapy in the management of chronic sinusitis involves sinus lavage with copious volumes of sterile sinusitis in horses is much less common than systemic treatment; saline, to which a broad-spectrum antibiotic or antiseptic however, it may be warranted in cases that are non-responsive to may be added (9). Systemic antibiotics are also commonly conventional therapy (9). Topical use of antimicrobials in cases used in treatment of primary sinusitis, for which the choice of of sinusitis has been limited to the addition of antimicrobials antibiotic is generally based on sample culture and sensitivity to the lavage solution (9). This is beneficial in that it allows for tests (5). However, while awaiting the culture and sensitivity antimicrobial action at the site of infection. However, since the results, treatment with penicillin, TMS, and/or metronidazole lavage solution drains from the sinus immediately, local antimi- is recommended, as these are effective antimicrobials against the crobial activity diminishes rapidly (9). Therefore, a technique to most common isolates in cases of sinusitis (3,10). Treatment of prolong local antimicrobial activity, such as the use of antibiotic secondary sinusitis requires removal of the inciting cause, in impregnated biomaterial, would likely improve the effective- addition to the therapies recommended for the treatment of ness of local therapy (17). While antimicrobial resistance is a primary sinusitis (5). In cases of chronic sinusitis, the response potential concern, the use of antibiotic impregnated biomate- rate can be poor and additional therapy and surgical drainage rial at the site of infection minimizes this risk, as it allows for are often required for successful treatment (5,11). prolonged drug concentrations above the minimum inhibitory Secondary sinusitis caused by underlying dental disease typi- concentration at the target site (17). In the case reported here, cally involves tooth removal either by oral extraction, buccot- minimal improvement was noted following 3 consecutive days omy, or repulsion (10). In this case, the patient had a fractured of transendoscopic sinus lavage and systemic antimicrobial tooth 109, an associated periapical infection, and concurrent therapy. The presence of inspissated purulent material was sinusitis; therefore, evaluation of the sinus in conjunction with the primary suspected reason for treatment failure. However, tooth repulsion surgery via maxillary bone flap technique was ineffective antimicrobial therapy, chronic inflammation, and the surgeon’s preferred treatment option. Serious complications accumulation of purulent material in the ventral conchal sinus of tooth repulsion surgery include chronic sinusitis, infection of were also considered as possible reasons for treatment failure a second tooth, bone sequestration, retained dental packing, and (6,11). Since the patient in this case was not responding to feed impaction (12). These complications have been noted to systemic antimicrobial therapy and sinus lavage, adjunctive occur in up to 32% to 70% of cases following tooth repulsion local therapy involving antibiotic impregnated biomaterial was surgery (11,13,14). Therefore, the fact that the horse in this deemed appropriate. report had paranasal sinusitis as a post-operative complication In conjunction with sinus lavage and systemic TMS, the of tooth repulsion surgery was not unforeseen. patient also received an intra-sinus antimicrobial infusion, which

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consisted of a gelatin/penicillin mixture. To the authors’ knowl- 2. Nickels F. Diseases of the paranasal sinuses. In: Auer J, Stick J, eds. edge, a gelatin/penicillin mixture has never been locally admin- Equine Surgery. 4th ed. St. Louis, Missouri: Saunders Elsevier, 2012: 563–565. istered into a sinus in the treatment of equine sinusitis; however, 3. Dixon P, O’Leary J. A review of equine paranasal sinusitis: Medical and it has been used locally in the guttural pouch to successfully treat surgical treatments. Equine Vet Educ 2012;24:143–158. empyema (1,18). In cases of guttural pouch empyema caused by 4. Tremaine W, Dixon P. A long-term study of 277 cases of equine sinonasal disease. Part 1: Details of horses, historical, clinical and ancillary S. equi, the gelatin/penicillin mixture improved the treatment diagnostic findings. Equine Vet J 2001;33:274–282. success rate due to its ability to remain in the pouches for a lon- 5. Freeman D. Sinus disease. Vet Clin Equine 2003;19:209–243. ger period of time than aqueous solutions (1,18). It has proven 6. Schumacher J, Honnas C, Barbara S. Paranasal sinusitis complicated by inspissated exudate in the ventral conchal sinus. Vet Surg 1987;16: to be a useful way to achieve high concentrations of penicillin 373–377. at the site of infection, while minimizing systemic absorption 7. Beard W, Hardy J. Diagnosis of conditions of the paranasal sinuses in (1,18,19). It was therefore believed that similar effects could be the horse. Equine Vet Educ 2001;13:265–273.

RAPPORTCAS DE 8. O’Leary J, Dixon P. A review of equine paranasal sinusitis. Aetiopatho achieved with its use in the case reported here, which was refrac- genesis, clinical signs and ancillary diagnostic techniques. Equine Vet tory to conventional therapies for sinusitis. Similar benefits were Educ 2011;23:148–159. noted in this case, as there was complete resolution of clinical 9. Pascoe J. Sinusitis. In: Smith B, ed. Large Animal Internal Medicine. 5th ed. St. Louis, Missouri: Mosby Elsevier, 2015:559–561. signs and there was no endoscopic evidence of sinusitis within 10. Bladon B, Munroe G. Paranasal sinuses. In: Munroe G, Weese J, eds. 1 wk of initiating the topical therapy. There are no reports of Equine Clinical Medicine, Surgery, and Reproduction. Boca Raton, adverse effects related to instillation of antimicrobials into the Florida: Taylor & Francis Group, 2011:395–400. 11. Tremaine W, Dixon P. A long-term study of 277 cases of equine sino- paranasal sinuses. In addition, no adverse effects were noted in nasal disease. Part 2: Treatments and results of treatments. Equine Vet this case, and the gelatin/penicillin mixture appears to be safe J 2001;33:283–289. and effective in cases of guttural pouch empyema (1). 12. Easley J, Freeman D. New ways to diagnose and treat equine dental- related sinus disease. Vet Clin Equine 2013;29:467–485. In conclusion, this report highlights the challenges that can 13. Dixon P, Tremaine W, Pickles K, et al. Equine dental disease part 4: be associated with the treatment of chronic sinusitis secondary A long-term study of 400 cases: Apical infections of cheek teeth. Equine to dental disease. Rapid culture and sensitivity testing and copi- Vet J 2000;32:182–194. 14. Prichard M, Hackett R, Erb H. Long-term outcome of tooth repulsion ous sinus lavage are essential for effective treatment. In addition, in horses: A retrospective study of 61 cases. Vet Surg 1992;21:145–149. the use of appropriate intra-sinus antimicrobials may also help 15. Ribeiro M, Risseti R, Bolanos C, et al. Trueperella pyogenes multispecies to improve the treatment outcome. To the authors’ knowledge, infections in domestic animals: A retrospective study of 144 cases (2002 to 2012). Vet Q 2015;35:82–87. this is the first report of intra-sinus gelatin/penicillin therapy 16. Songer J, Post K. The genus Arcanobacterium. In: Veterinary as an adjunct treatment for chronic sinusitis. This therapy may Microbiology: Bacterial and Fungal Agents of Animal Disease. St. Louis, represent a unique additional therapy for complex sinusitis cases Missouri: Saunders Elsevier, 2005:59–60. 17. Richardson D, Ahern B. Synovial and osseous infections. In: Auer J, involving susceptible bacteria. Stick J, eds. Equine Surgery. 4th ed. St. Louis, Missouri: Saunders Elsevier, 2012:1192–1193. Acknowledgment 18. Sweeney C, Timoney J, Newton J, Hines M. Streptococcus equi infections in horses: Guidelines for treatment, control, and prevention of strangles. The authors thank Dr. Nora Biermann for her valuable assis- J Vet Intern Med 2005;19:123–134. tance with this case. CVJ 19. Magdesian K. b-lactam antimicrobials. In: Robinson N, Sprayberry K, eds. Current Therapy in Equine Medicine. 6th ed. St. Louis, Missouri: References Saunders Elsevier, 2009:10–11. 1. Verheyen K, Newton J, Talbot N, Brauwere M, Chanter N. Elimination of guttural pouch infection and inflammation in asymptomatic carriers of Streptococcus equi. Equine Vet J 2000;32:527–532.

292 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY Brief Communication Communication brève

Significance of cytological smear evaluation in diagnosis of splenic mast cell tumor-associated systemic mastocytosis in a cat (Felis catus)

Moges Woldemeskel, Anita Merrill, Cindy Brown

Abstract — An 8-year-old cat was presented with vomiting and weight loss. Histopathology and cytology revealed systemic mastocytosis, a rare condition and a clinical challenge. This case emphasizes the significance of cytological evaluation of smears in diagnosis of mastocytosis and in confirmation in biopsy specimens.

Résumé — Signification de l’évaluation d’un frottis cytologique dans le diagnostic d’une mastocytose systémique chez un chat (Felis catus) associée à une tumeur des mastocytes spléniques. Un chat âgé de huit ans a été présenté avec des vomissements et une perte de poids. L’histopathologie et la cytologie ont révélé une mastocytose systémique, une affection rare et difficile sur le plan clinique. Ce cas met en lumière l’importance de l’évaluation cytologique des frottis pour le diagnostic de la mastocytose et la confirmation pour les spécimens de biopsie. (Traduit par Isabelle Vallières) Can Vet J 2017;58:293–295 hree general forms of mast cell tumors (MCTs) are rec- pected. Smears from peripheral blood were stained with Wright’s T ognized in the cat. These are cutaneous MCT, visceral Giemsa stain for microscopic evaluation. Blood parasites were MCT, and MCT of the hematopoietic system, which includes not observed, but numerous MCs [10 MCs/100 white blood the spleen, liver, and bone marrow (1). Systemic mastocytosis cells (WBC)] were present in the smears. The MCs exhibited is widely recognized as an event of neoplastic mast cell (MC) rare mitoses and erythrophagocytosis. Scattered reactive lym- proliferation involving multiple visceral organs especially spleen, phocytes and nucleated erythrocytes (9 nucleated RBCs/100 liver, and bone marrow and, in the cat, often follows feline WBC) were also present in the smears. On automated complete hematopoietic system MCT. The nomenclature used is highly blood (cell) count (CBC; ADVIA 2120i Hematology System; variable and includes mast cell leukemia, systemic mastocytosis, Siemens, Malvern, Pennsylvania, USA) the total WBC was and disseminated mastocytosis (2). 16.07 3 109/L [reference interval (RI): 5.5 to 19.5 3 109/L], Systemic mastocytosis is a rare finding in cats. Incidental and there was moderate lymphocytosis (10.79 3 109/L; RI: detection of circulating MCs (mastocythemia) during blood 1.5 to 7.0 3 109/L) and moderate normochromic, normo- smear evaluation is rare, with an incidence of 0.05% to 0.33% cytic anemia [RBC: 3.2 3 1012/L, RI: 5.0 to 10.0 3 1012/L; (3,4). Cats with systemic mastocytosis are commonly presented hemoglobin (HGB): 3.2 mmol/L, RI: 5.0 to 9.3 mmol/L; and with depression, anorexia, weight loss, and intermittent vomit- hematocrit (HCT): 16.19%, RI: 25% to 45%]. An MCT was ing (1). The clinical signs are nonspecific, rendering diagnosis suspected and the cat was treated with prednisone and antibiot- of the disease a clinical challenge. ics. There was no response to treatment and the owner elected An 8-year-old, spayed female domestic shorthaired cat (Felis euthanasia due to anorexia and weight loss. The body was catus) was evaluated because of vomiting, decreased appetite, submitted to Tifton Veterinary Diagnostic and Investigational and weight loss. On clinical examination, the mucous mem- Laboratory, University of Georgia, USA, for examination. branes were pale and hemoparasite-associated anemia was sus- On necropsy, the cat was found to be in good body condition. The spleen was markedly enlarged (Figures 1A and 1B) and weighed 210 g. The liver was pale yellow and moderately University of Georgia, College of Veterinary Medicine, enlarged (184 g). Wright’s Giemsa-stained impression smears Veterinary Diagnostic and Investigational Laboratory, made from cut surfaces of the spleen showed a monomorphic 43 Brighton Road, Tifton, Georgia 31793 (Woldemeskel, population of round cells with abundant cytoplasmic meta- Merrill); Plantation Center Animal Hospital, 6411 Peake Road, chromatic granules, consistent with MCs (Figure 1C). Large Macon, Georgia 31210, USA (Brown). numbers of erythrocytes, scattered lymphocytes, and rare neu- Address all correspondence to Dr. Moges Woldemeskel; e-mail: trophils were also present. Tissue specimens collected in 10% [email protected] buffered formalin solution were processed for routine histopa- Use of this article is limited to a single copy for personal study. thology and stained with hematoxylin-eosin. On microscopic Anyone interested in obtaining reprints should contact the examination, round cells diffusely infiltrated the spleen, liver, CVMA office ([email protected]) for additional hepatic sinusoids and veins, pancreatic vessels, and mesenteric, copies or permission to use this material elsewhere. pre-scapular and mandibular lymph nodes. Mitotic cells were

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Figure 1. Splenic mast cell tumor with systemic mastocytosis in a cat. A and B — Markedly enlarged spleen (splenomegaly, arrows) at necropsy. C — Neoplastic mast cells in splenic impression smear (Wright’s Giemsa stain): an arrow shows erythrophagocytosis. Spleen (D), liver (E), and lymph node (F) 5-mm tissue sections infiltrated with neoplastic mast cells (arrows). Toluidine blue stain. HP — hepatic parenchyma; LF — lymphoid follicle.

rare. Abundant cytoplasmic metachromatic granules were With the appearance of increased MCs in peripheral blood, observed in the infiltrative round cells, in additional sections MCT, particularly splenic MCT and systemic mastocytosis of spleen, liver, and lymph nodes stained with Toluidine blue should be considered in the cat (8). Affected cats are presented (Figures 1D, 1E, and 1F). Mast cells were not observed in sec- with nonspecific signs of systemic illness and hematologic tions of bone marrow. abnormalities (3,5). Because visceral MCT in cats often shares Hematologic, cytological, postmortem, and histologic find- clinical signs with other diseases, it may not be recognized if ings were consistent with systemic mastocytosis associated overt splenomegaly is not detected and fine-needle aspirates of with splenic MCT, as demonstrated by splenomegaly and dis- the affected internal organs are not examined (3). Even in the semination of MCs in multiple tissues. Histopathological results presence of a clinical diagnosis other than MCT, additional tests, substantiated the cytological findings in the blood smears. This including fine-needle aspirates of spleen and liver, are warranted case is interesting in that detection of circulating MCs during to rule out occult MCT, as clinical signs of visceral MCT are blood smear evaluation is a very rare finding in cats. Circulating insidious and may be masked by concurrent diseases (3). MCs in the cat are usually suggestive of systemic mastocytosis Mastocythemia may be detected by examination of periph- associated with visceral MCT; and in this case splenic MCT. eral blood smear, a bone marrow aspirate, or a buffy-coat (5). In cats with splenic MCT, dissemination occurs into the liver, Cytological evaluation of peripheral blood smears should be visceral lymph nodes, bone marrow, lung, and intestine (5,6). In done in cats with weight loss and vomiting of unknown cause the present case, MCs were observed in spleen, liver, pancreatic to rule out mastocythemia. Examination of the buffy-coat is the vessels, and various lymph nodes, and were not observed in the preferred method for detection of mastocythemia in cases of bone marrow. known or suspected MCT or in cats with splenomegaly (4). The Systemic mastocytosis in cats appears almost exclusively asso- buffy-coat was not examined in the current case and numerous ciated with visceral MCTs and frequently associated with splenic MCs were readily observed in blood smears suggesting systemic MCT. This is different from that in dogs, in which systemic mastocytosis. Histopathology confirmed the presence of MCs mastocytosis is not pathognomonic for MCT, but can occur in in various visceral organs. association with various inflammatory conditions, hypersensitiv- Marked splenomegaly is the characteristic gross lesion of ity, tissue injury, necrosis, and severe regenerative anemia (7). systemic mastocytosis in the cat (9). Cytology on fine-needle

294 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY aspirates of affected organs are usually diagnostic (8) and Therefore, cytological evaluations of smears from peripheral histopathology of biopsy from affected tissue is confirmatory. blood and aspirates of enlarged organs such as spleen should be Although mastocythemia in the cat is rare and often associated made in suspected patients or those that show weight loss and

with visceral MCT, rare circulating MCs may also be seen with vomiting of unknown cause. This case is an interesting, rare BRIEF COMMUNICATION diseases other than MCT (3). Thus, examination of the patient case reporting detection of circulating MCs during blood smear for splenomegaly and involvement of other visceral organs for evaluation in a cat. The report underscores the significance of MCT should be done in cases in which MCs are observed in cytological evaluation of peripheral blood smear and/or aspi- peripheral blood smears. Therefore, ultrasound imaging would rate of enlarged visceral organs including spleen in diagnosing help to assess for enlarged visceral organs such as the spleen visceral MCT-associated systemic mastocytosis in the cat to and to obtain ultrasound-guided fine-needle aspirates or fine- facilitate rapid initiation of appropriate treatment. needle biopsy for cytological and histopathological evaluations, respectively. This helps to confirm the diagnosis and institute Acknowledgment appropriate treatment. The authors thank the staff at Tifton Veterinary Diagnostic As was observed in this case, mastocytemic cats with MCT and Investigational Laboratory, University of Georgia, for their have a low HCT value (4). Anemia of chronic disease, blood technical assistance. CVJ loss due to gastrointestinal (GIT) ulceration, splenic erythrocyte References sequestration, antibody-coated erythrocyte removal by splenic 1. Allan R, Halsey TR, Thompson KG. Splenic mast cell tumour and mas- macrophages and erythrophagocytosis by neoplastic MCs have tocytaemia in a cat: Case study and literature review. N Z Vet J 2000; been suggested to underlie the low HCT values in cats with 48:117–121. splenic MCT and systemic mastocytosis (1,5). Ulceration of 2. Lamm CG, Stern AW, Smith AJ, Cooper EJ, Ullom SW, Campbell GA. Disseminated cutaneous mast cell tumors with epitheliotropism and the GIT was not present in the current case. Although eryth- systemic mastocytosis in a domestic cat. J Vet Diagn Invest 2009;21: rophagocytic MCs were observed in the peripheral blood and 710–715. splenic impression smears, the significance of erythrophagocytic 3. Piviani M, Walton RM, Patel RT. Significance of mastocytemia in cats. Vet Clin Pathol 2013;42:4–10. MCs in causing low HCT in this case remains speculative. 4. Skeldon NC, Gerber KL, Wilson RJ, Cunnington SJ. Mastocytaemia Vomiting, which is another common clinical sign observed in in cats: Prevalence, detection and quantification methods, haemato- cats with MCT, may be caused by gastroduodenal ulceration or logical associations and potential implications in 30 cats with mast cell tumours. J Feline Med Surg 2010;12:960–966. displacement of the abdominal viscera by an enlarged spleen 5. Hyaland JE, Sartin EA, Spangler EA. Pathology in practice. Splenic mast (10). Because gastroduodenal ulceration was not observed in the cell tumor with metastasis to the liver in a cat. J Am Vet Med A 2013; present case, vomiting was likely associated with displacement 242:627–629. 6. Graille M, Huyghe FP, Nicolier A. Mastocytemia associated with a of abdominal viscera due to splenomegaly. visceral mast cell tumor in a Sumatran tiger (Panthera tigris). J Zoo Following confirmation of feline splenic MCT and systemic Wildl Med 2013;44:189–192. mastocytosis, splenectomy and treatment with corticosteroids are 7. McManus PM. Frequency and severity of mastocytemia in dogs with and without mast cell tumors: 120 cases (1995–1997). J Am Vet Med reported to result in remission of clinical signs (1). Splenectomy Assoc 1999;215:355–357. is generally recommended in cases of splenic MCT and associ- 8. Antognoni MT, Spaterna A, Lepri E, Fruganti A, Laus F. Characteristic ated mastocythemia due to long-term survival documented in clinical, haematological and histopathological findings in feline masto- cytoma. Vet Res Commun 2003; 27 Suppl 1:727–730. cases so treated (4). Survival times after splenectomy varied from 9. Jacobs RM, Messick JB, Valli VE. Tumors of hemolymphatic system: 0 to 38 mo (1,4). The cat herein failed to respond to treatment Mast cell leukemia. In: Meuton DJ, eds. Tumors in Domestic Animals. with prednisone and antibiotics. Antibiotics were given to pro- 4th ed. Ames, Iowa: Iowa State University Press, 2002:190–192. 10. Liska WD, MacEwen EG, Zaki FA, Garvey M. Feline systemic masto- tect against possible immunosuppression-associated secondary cytosis: A review and results of splenectomy in seven cases. J Am Anim and/or concurrent bacterial infections. Splenectomy was not Hosp Assoc 1979;15:589–597. done. Feline MCTs have also been reported to show potent 11. Isotani M, Tamura K, Yagihara H, et al. Identification of a c-kit exon 8 internal tandem duplication in a feline mast cell tumor case and its response to kinase inhibitors (11). The long-term outcome fol- favorable response to the tyrosine kinase inhibitor imatinib mesylate. lowing this treatment remains to be determined. Vet Immunol Immunopathol 2006;114:168–172. In summary, detection of MCs during routine blood smear evaluation is rare but it is a strong indication of visceral MCT.

CVJ / VOL 58 / MARCH 2017 295 FOR PERSONAL USE ONLY Brief Communication Communication brève

Experimental infection with Mycobacterium avium subspecies paratuberculosis resulting in decreased body weight in Holstein-Friesian calves

Gwendolyn L. Roy, Jeroen De Buck, Robert Wolf, Rienske A.R. Mortier, Karin Orsel, Herman W. Barkema

Abstract — Fifty calves inoculated at either 2 weeks or at 3, 6, 9, or 12 months of age with either a low or high dose of Mycobacterium avium subspecies paratuberculosis (MAP) were on average 32 and 39 kg lower in body weight, respectively, compared to negative controls at 17 months of age.

Résumé — Chute du poids corporel chez des veaux Holstein-Friesian suite à l’infection expérimentale avec Mycobacterium avium sous-espèce paratuberculosis. Cinquante veaux qui ont été inoculés à l’âge de 2 semaines ou à l’âge de 3, 6, 9 ou 12 mois avec soit une dose faible ou élevée de Mycobacterium avium sous-espèce paratuberculosis (MAP) présentaient en moyenne un poids corporel inférieur de 32 kg et de 39 kg respectivement, comparativement aux témoins négatifs à l’âge de 17 mois. (Traduit par Isabelle Vallières) Can Vet J 2017;58:296–298

ycobacterium avium subspecies paratuberculosis (MAP) Additionally, calves of strong ELISA-positive beef cows (defined M is the causative agent of Johne’s disease (JD), a gastro- as an S/P ratio . 0.99 or . 3.49 for the Herdcheck and the intestinal disease in ruminants. Although cattle are in general Paracheck ELISA, respectively), and calves of heavy or moderate infected as calves (1), due to JD’s chronic nature, typically MAP shedders had a 21 and 59 kg reduced 205-day adjusted older cattle (between 2 and 6 years of age) present with signs. weaning weight compared to calves of ELISA-negative and MAP Only a small percentage of MAP-infected animals will have culture-negative dams, respectively (8). Decreased weight could clinical JD; many more are infected, but are subclinical (2). be due to lower milk yield of the dam and/or a direct effect The latter animals may shed MAP intermittently (1), creating of MAP infection on the offspring. However, dairy calves are an environmental reservoir. usually separated from their dams shortly after birth, and lower Following ingestion, MAP invades the wall of the intestinal milk yield of the dam would not affect growth of the calf. To tract. Microscopic and macroscopic lesions inhibit absorption of our knowledge, there are no reports on the effects of MAP infec- nutrients through the gut lining, particularly in the small intes- tion on body weight of dairy young stock. The objective of this tine. Furthermore, energy must be expended by the animal to study, therefore, was to quantify the effect of MAP inoculation mount an immune response (2). Subclinical infection with MAP on weight in dairy bull calves. results in lower milk yields, poor reproductive performance, and The design of the overall study was described by Mortier reduced value of culled cows, thereby reducing profitability (3). et al (9) and was conducted under the University of Calgary Dairy cows that were milk MAP enzyme-linked immunosorbent Health Sciences Animal Care Committee permits M09083 and assay (ELISA)-positive weighed 10% less at slaughter than milk M09050. Briefly, 56 Holstein-Friesian bull calves were collected ELISA-negative cows (4). Furthermore, if the cow was shed- on farms with an adult cow serum ELISA prevalence , 5%. To ding MAP, its weight was on average 15% less compared to prevent bacterial contamination, newborn calves were collected non-shedders (4). Subclinical infection with MAP also reduces directly from a MAP ELISA-negative dam without touching weight at slaughter of sheep (5), deer (6), and beef cattle (7). the ground. These calves were brought to our research facility, individually housed, and careful biosecurity consistently practiced to prevent cross-contamination. Fifty calves were Department of Production Animal Health, Faculty of Veterinary randomly allocated to 5 MAP-inoculation age groups and Medicine, University of Calgary, Calgary, Alberta. 6 calves were not challenged with MAP (i.e., negative controls). Address all correspondence to Dr. Herman W. Barkema; e-mail: Mycobacterium avium subsp. paratuberculosis was cultured [email protected] from a cow with clinical JD, and was given orally as either a Use of this article is limited to a single copy for personal study. high dose [5 3 109 colony-forming units (CFU)] or low dose Anyone interested in obtaining reprints should contact the (5 3 107 CFU). Groups of 10 calves were each inoculated at CVMA office ([email protected]) for additional either 2 wk or at 3, 6, 9, or 12 mo of age. For each infection copies or permission to use this material elsewhere. group, 5 calves were inoculated with a high dose of MAP; the

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Table 1. Final linear regression model for body weight (kg) of 600 50 Holstein-Friesian steers inoculated and 6 steers not inoculated 465 451 454 456 445 489 with Mycobacterium avium subspecies paratuberculosis 500 Coefficient SE P-value 95% CI 400 BRIEF COMMUNICATION Intercept 275.8 173.5 0.66 2424.0 to 272.4 Age at euthanasia (d) 1.16 0.33 0.001 0.50 to 1.81 300 Dose Low 232.2 11.5 0.007 255.2 to 29.1 200 High 239.3 11.5 0.001 262.4 to 216.3 a Trial 222.3 7.1 0.003 236.6 to 28.0 100 a The experiment was conducted in 2 consecutive trials. SE — standard error; CI — confidence interval. (kg) necropsy at weight Average 0 0.5 3 6 9 12 C Age at inoculation (months) other 5 calves were inoculated with a low dose. Inoculation Figure 1. Average weight at necropsy (corrected for age of took place on 2 consecutive days. Because of the limited capac- necropsy) for the 5 ages at which the cattle were inoculated with ity of the research facility, the experiment was conducted with Mycobacterium avium subspecies paratuberculosis. Each bar 2 identically conducted consecutive trials of 33 and 23 calves represents the mean 6 standard deviation. Negative controls (labeled C) had a greater average weight (P = 0.006). with equal representation of all age groups and negative controls in each trial. The work started in January 2010 and ended in August 2011, for Trial 1, and started in May 2011 and ended The combination of diagnostic tests performed on the inocu- in December 2012, for Trial 2. Calves were dehorned under lated calves demonstrated that most of the calves were indeed local anesthesia using a cauterizing iron and they were surgically infected, with positive fecal shedding in 61% (10), positive castrated after administration of sedation and local anesthesia. antibody ELISA in 42% (11), MAP-positive tissues in 56% Calves were individually housed on deep bedding (pine shav- and overall 90% of the calves positive by either tissue culture, ing substrate). Within 12 h after birth calves were given 6 L of macroscopic lesions, fecal shedding and/or ELISA (9) and colostrum which had been collected from 7 MAP seronegative 100% by interferon-gamma release assay (12). Because all calves and environmental culture-negative Alberta dairy farms and inoculated with MAP were interferon-gamma positive and the gamma-irradiated. Thereafter, calves were bucket fed 1.5 L of sensitivity of the other tests is relatively low, we decided to Grober High Performance milk replacer (Grober Nutrition, include all inoculated calves in the analysis. Cambridge, Ontario) thrice daily for 3 d. They were then given Steers gained on average 1.16 kg/d, and there was a 22.3 kg 2 L thrice daily for 3 d, and finally 3 L twice daily until wean- difference in weight between the first and second trials (Table 1). ing. The milk was fed by a researcher wearing separate coveralls, Mean weight was not associated with the age at which the cattle boots, and gloves for each calf. At 7 to 8 wk of age, calves were were inoculated with MAP (Figure 1). Consequently, inocula- weaned using a week-long process, during which they were fed tion age was not included in the final model. Negative control half the milk replacer powder in the same volume of water. steers had a higher mean body weight; those inoculated with Calves were weaned onto a diet of high-quality timothy hay a low dose of MAP weighed on average 32.2 kg less than con- ad libitum and approximately 500 g of concentrate (pelleted mix trol steers, whereas steers inoculated with a high dose weighed containing vitamins and trace minerals). The ration increased as 39.3 kg less than control steers (Table 1). the calves aged and the concentrate was doubled on days when Two steers developed clinical JD and were subsequently eutha- the temperature in the barn was below 220°C. All steers had nized early (to mitigate welfare concerns). Inclusion or exclusion access to water ad libitum. of these 2 steers had limited effects on results (inclusion reduced Blood and fecal samples were collected both pre-exposure the high-dose group’s average weight by a further 2 kg). Therefore, and at fixed intervals after inoculation (9). The number of pre- these 2 animals were ultimately included in the analysis. inoculation samples depended on age of inoculation, with every It is unfortunate that calves were not weighed shortly after animal sampled at least once before inoculation. Samples were birth and more frequently during the experiment. It is unlikely, collected at 2 and 4 d after inoculation, then weekly for 4 wk, however, that the difference in weight at necropsy was the result and finally, monthly until euthanasia. Steers were euthanized of a difference in birth weight, growth potential between control at approximately 17 mo of age with an overdose of sodium versus inoculated calves, or differences in feeding or housing, pentobarbitone (Euthapent; Kyron Laboratories, Johannesburg, because infection dose was assigned randomly, and treatment South Africa). Immediately after euthanasia, body weight was and housing were standardized. Control calves were collected determined with a spring scale that was raised by a forklift and randomly throughout the 2 consecutive trials and were indi- attached to a hind limb of the carcass. vidually housed among inoculated calves. Feeding was not done Differences in age-adjusted weight at necropsy between MAP according to MAP status. Including birth weight in the analysis, dose groups, age at inoculation, and trials were analyzed using a however, would have made the estimate more precise, and more linear regression model (Stata 12.1, Stata Corp., College Station, frequent weighing would have enabled determination of when Texas, USA). For all analyses, P , 0.05 was considered statisti- the decrease in growth after MAP infection started. cally significant. Stepwise regression with backward elimination The difference in body weight in the 2 consecutive trials was done to identify variables associated with weight at necropsy. may have arisen for several reasons. The cattle in the first trial

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were slightly older (average = 5.6 d at slaughter); however, age Acknowledgments at necropsy was included in the model for the final dose effect. This work was supported by Alberta Innovates — Bio Solutions, Additionally, the first trial and the second trial ended in differ- the Alberta Livestock and Meat Agency, Alberta Milk, Dairy ent seasons. As the barn was not heated and there were fewer Farmers of Canada, the Natural Sciences, Engineering Research cattle in the second trial, growth rate in the cattle in the second Council of Canada, and University of Calgary, Faculty of trial may have decreased as the outdoor temperature decreased. Veterinary Medicine. The authors acknowledge numerous Cattle in the first trial may have had compensatory growth undergraduate students who collaborated in this experiment after the winter, as the trial ended in the summer (July and and Dr. John Kastelic who edited the manuscript. CVJ August). Finally, feed quality varied over both years. Although high-quality hay was sourced, it was not possible to ensure the References hay from both years was exactly equivalent. 1. Mortier RAR, Barkema HW, De Buck J. Susceptibility to and diagnosis In 3 US cow-calf beef herds, weaned calves from serum of Mycobacterium avium subspecies paratuberculosis infection in dairy

COMMUNICATIONBRÈVE ELISA-positive dams were on average 33 kg lighter than calves calves: A review. Prev Vet Med 2015;121:189–198. 2. Tiwari A, VanLeeuwen JA, McKenna SL, Keefe GP, Barkema HW. from non-positive cows (8). Weight at 205 d of age for calves Johne’s disease in Canada Part I: Clinical symptoms, pathophysiology, from ELISA-positive dams was 21 kg less than that of calves of diagnosis, and prevalence in dairy herds. Can Vet J 2006;47:874–882. ELISA-negative dams. The difference was even larger compar- 3. McKenna SL, Keefe GP, Tiwari A, VanLeeuwen J, Barkema HW. Johne’s disease in Canada part II: Disease impacts, risk factors, and control ing calves of moderate or heavy MAP shedders to those of programs for dairy producers. Can Vet J 2006;47:1089–1099. fecal culture-negative dams (59 and 41 kg, respectively). The 4. Kudahl AB, Nielsen SS. Effect of paratuberculosis on slaughter weight researchers speculated that the weight loss was either because and slaughter value of dairy cows. J Dairy Sci 2009;92:4340–4346. 5. Morris CA, Hickey SM, Henderson HV. The effect of Johne’s disease the dams produced less milk and/or because of direct effects on production traits in Romney, Merino and Merino x Romney-cross of MAP infection on calves. Quantity and quality of milk was ewes. N Z Vet J 2006;54:204–209. controlled in our study, and body weight at necropsy was low- 6. Murray HL, Yabsley MJ, Keel MK, Manning EJ, Wilmers TJ, Corn JL. Persistence of Mycobacterium avium subspecies paratuberculosis in est in the steers inoculated with the high dose; therefore, we endangered Florida Key deer and Key deer habitat. J Wildl Dis 2014; inferred that weight loss in calves in the previous study (8) was 50:349–353. due to MAP infection. 7. Elzo MA, Rae DO, Lanhart SE, Hembry FG, Wasdin JG, Driver JD. Association between cow reproduction and calf growth traits and ELISA Worldwide, a high proportion of dairy farms is infected with scores for paratuberculosis in a multibreed herd of beef cattle. Trop MAP (13,14), and the proportion of calves already shedding Anim Health Prod. 2009;41:851–858. MAP is relatively high in infected dairy farms (15). Lower body 8. Bhattarai B, Fosgate GT, Osterstock JB, Fossler CP, Park SC, Roussel AJ. Comparison of calf weaning weight and associated economic variables weights were not only present in calves inoculated with a high between beef cows with and without serum antibodies against or isola- MAP dose, but also in calves inoculated with a low dose, which tion from feces of Mycobacterium avium subsp paratuberculosis. J Am may be more representative of exposure under field conditions Vet Med Assoc 2013;243:1609–1615. 9. Mortier RAR, Barkema HW, Bystrom JM, et al. Evaluation of on infected dairy farms. It is therefore likely that economic age-dependent susceptibility in calves infected with two doses of losses caused by MAP infection are underestimated, as to our Mycobacterium avium subspecies paratuberculosis using pathology knowledge none included decreased weight in calves. and tissue culture. Vet Res 2013;44:94. 10. Mortier RAR, Barkema HW, Orsel K, Wolf R, de Buck J. Shedding Although this was a large challenge experiment, the number patterns of dairy calves experimentally infected with Mycobacterium of cattle was relatively low in the individual groups, which was avium subspecies paratuberculosis. Vet Res 2014;45:71. probably the reason why no significant difference in weight 11. Mortier RAR, Barkema HW, Negron M, Orsel K, Wolf R, de Buck J. Antibody response early after experimental infection with Mycobacterium between the age groups was found. Furthermore, the relatively avium subspecies paratuberculosis in dairy calves. J Dairy Sci 2014;97: low sample size made it not possible to exactly predict a weight 5558–5565. difference between infected and uninfected cattle. However, the 12. Mortier RAR, Barkema HW, Wilson TA, Sajobi TT, Wolf R, de Buck J. Dose-dependent interferon-gamma release in dairy calves experimentally purpose of the study was to determine whether MAP infection infected with Mycobacterium avium subspecies paratuberculosis. Vet impacts cattle growth instead of quantifying the difference. Immunol Immunopathol 2014;161:205–210. In conclusion, MAP infection in cattle is more costly than 13. Barkema HW, Hesselink JW, McKenna SLB, Benedictus G, Groenendaal H. Global prevalence and economics of infection with previously considered because of a negative effect of subclinical Mycobacterium avium subsp. paratuberculosis in ruminants. In: Behr infections on young stock weight. Good management practices MA, Collins DM, eds. Paratuberculosis: Organism, Disease, Control. with both dairy and beef herds are paramount to reducing Wallingford, Oxfordshire, UK: CAB International, 2010:10–21. 14. Wolf R, Barkema HW, De Buck J, et al. High herd-level preva- JD prevalence. These management practices should be main- lence of Mycobacterium avium subspecies paratuberculosis in Western tained for cattle of all ages, as exposure to MAP, even at 1 y of Canadian dairy herds, based on environmental sampling. J Dairy Sci age, resulted in the same average weight reduction as in cattle 2014;97:6250–6259. 15. Wolf R, Orsel K, De Buck J, Barkema HW. Calves shedding exposed at younger ages. Careful management should be used by Mycobacterium avium subspecies paratuberculosis are common on both dairy and beef producers to ensure that uninfected cattle infected dairy farms. Vet Res 2015;46:71. remain free of MAP.

298 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY Student Paper Communication étudiante

Severe unilateral buphthalmos in a 4-month-old kitten

Gillian Finnie

Abstract — A 4-month-old kitten was presented with unilateral buphthalmos. The eye was blind with no menace response, but intraocular pressure was normal. A trans-palpebral enucleation was performed on the affected eye and the globe was submitted for histology. There was a suppurative, lympho-plasmacytic panophthalmitis with inflammatory exudate in the iridocorneal angle.

Résumé — Buphthalmie unilatérale grave chez un chaton âgé de 4 mois. Un chaton âgé de 4 mois a été présenté avec de la buphtalmie unilatérale. L’œil était aveugle sans réponse à la menace, mais la pression intraoculaire était normale. Une énucléation trans-palpébrale a été réalisée sur l’œil affecté et le globe a été soumis pour examen histologique. Il y avait une panophtalmitie lympho-plasmacytique avec de l’exsudat inflammatoire dans l’angle irido-cornéen. (Traduit par Isabelle Vallières) Can Vet J 2017;58:299–301

4-month-old intact male domestic kitten was presented to weight (BW), PO, q24h for the 3 d prior to surgery. For sur- A O’Dowd Veterinary Hospital in Ardee, Ireland with severe gery, the kitten received medetomidine (Medetor; Chanelle unilateral buphthalmos of the right eye. Diffuse corneal edema Group, Galway, Ireland), 0.08 mg/kg BW, IM, butorphanol and dorsal conjunctival hyperemia were visible and the corneal (Butador; Chanelle Group), 0.4 mg/kg BW, IM, and ketamine surface suffered from exposure. The eye was unresponsive to a (Ketamidor; Chanelle Group), 5 mg/kg BW, IM, in combi- menace test and had a fixed, dilated pupil. Intraocular pressure nation and was maintained on isoflurane general anesthetic. (IOP), measured with a handheld tonometer (Tono-Pen VET; Meloxicam (0.3 mg/kg BW, SQ) and amoxicillin (Betamox LA; Reichert, Depew, New York, USA), was 19 mmHg, averaged Norbrook, Monaghan, Ireland), 15 mg/kg BW, SQ, were given over 4 readings. The IOP of the left eye was within normal before surgery. The trans-palpebral enucleation was performed limits (range: 15 to 25 mmHg), averaged over 4 readings. as described (1). The kitten recovered quickly from surgery and Buphthalmos, or gross enlargement of the ocular globe, in the with good attitude. The globe was submitted in 10% buffered presence of normal IOP is an indication of prolonged exposure formalin to IDEXX Laboratories (Wetherby, England) for histol- to increased intraocular pressure. Chronic glaucoma was diag- ogy. Meloxicam, 0.06 mg/kg BW, PO, q24h, was prescribed for nosed. The left eye showed no signs of abnormality and retained 1 wk starting the day after surgery. At the recheck 2 wk later, vision. The kitten was otherwise normal on physical examina- the kitten was fully recovered and skin sutures were removed. tion and had good attitude. The client reported no change in The histology report revealed suppurative and lympho- behavior and perceived relatively little discomfort in the time plasmacytic panophthalmitis with locally extensive corneal before presentation. ulceration. There was stromal corneal edema and infiltration of An enucleation surgery was scheduled to remove the affected degenerate neutrophils. The anterior chamber was filled with eye. The patient was treated with meloxicam (Metacam; degenerate neutrophils and fibrin indicating severe uveitis and Boehringer Ingelheim, Rhein, Germany), 0.06 mg/kg body infection that could be grossly observed as hypopyon and aqueous flare. An accumulation of inflammatory cells and exudate was seen in the iridocorneal angle causing the aqueous outflow Ontario Veterinary College, University of Guelph, 50 Stone obstruction responsible for development of glaucoma. There was Road East, Guelph, Ontario N1G 2W1. severe inflammation of the ciliary body and choroid extending Address all correspondence to Gillian Finnie; e-mail: to the retina. Retinal detachment and hypertrophy of retinal [email protected] pigment epithelium were observed with severe inflammation Ms. Finnie will receive 50 copies of her article free of charge and inflammatory infiltrate posterior to the detachment. courtesy of The Canadian Veterinary Journal. Use of this article is limited to a single copy for personal study. Discussion Anyone interested in obtaining reprints should contact the Glaucoma is defined as an increase in intraocular pressure CVMA office ([email protected]) for additional above the normal range (15 to 25 mmHg) non-conducive to copies or permission to use this material elsewhere. ocular health. Aqueous fluid produced by the ciliary body flows

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A B COMMUNICATIONÉTUDIANTE

Figure 1. Severe unilateral buphthalmos of the right eye in a 4-month-old kitten. A — Diffuse corneal edema and dorsal conjunctival hyperemia are grossly visible. B — Hematoxylin & eosin (H&E) stained histology section showing the iridocorneal angle, 53 magnification. Obstruction is due to the inflammatory cells and exudate apparent within the angle.

forward through the pupil and into the anterior chamber to with inflammatory cells and exudate obstructing aqueous eventually exit the eye at the margin of the iris and cornea, the outflow at the iridocorneal angle. In this kitten, trauma is the iridocorneal angle. Glaucoma occurs when the fluid accumu- suspected cause of injury resulting in secondary uveitis that lates, increasing the pressure within the eye. In cats, glaucoma progressed to glaucoma and eventually buphthalmos. Histology is considered insidious and progressive, often presenting late detected locally extensive corneal ulceration that may represent in the course of disease with irreversible damage and blindness the initial site of injury, although it is also possible that the (2,3). Diagnosis is made by determining that intraocular pres- observed ulceration is a consequence of exposure keratopathy sure (IOP) is . 25 mmHg in conjunction with clinical signs. from difficulty closing the lids over the enlarged eye. Compared In this case the presence of an overt buphthalmos indicated that to other species, corneal edema and Haab’s striae, or cracks in there had previously been chronic high IOP despite normal Descemet’s membrane, are rarely seen in cats (4,5). In 1 study values at presentation. This is possible when prolonged pressure when corneal edema was observed, there was concurrent corneal increases cause globe distention and reduced fluid production ulceration present, as in this case (5). Inflammatory damage to from damage to the ciliary body (3). the retina is the probable mechanism for the observed retinal Primary or secondary glaucoma is categorized by the under detachment, which was followed by a hypertrophic response of lying cause of the increased IOP. Primary glaucoma is the result the retinal pigment epithelium (7). of a malformation of the iridocorneal angle, the structure that Further characterization of a glaucoma case can help drains aqueous fluid in clinically normal patients. Although determine the inciting cause and the best clinical approach. uncommon, it is reported in Siamese and Burmese cats and can Chronicity can be determined by the presence of buphthalmos, present in other breeds as well (3,4). Often initially unilateral, blindness, cupping of the optic disc, and deep corneal vascu- eventually both eyes are affected (4). This is important to con- larization (or “limbal blush”) (4). Buphthalmos occurs much sider in cats in which primary glaucoma is suspected so that the more quickly in young animals due to increased distensibility best approach may be determined and to appreciate the necessity of their globes (3,7). Blindness in glaucoma is the result of the of monitoring and management of the opposite eye. increased pressure causing retinal and optic disc damage (6). Secondary glaucoma develops when increased ocular pres- Retinal damage can be observed as the attenuation of retinal sure occurs as a result of a separate initiating disease process. vessels and hyperreflectivity of the fundus on ophthalmoscopic Chronic lympho-plasmacytic uveitis and intraocular neoplasia examination (4). Whether the damage is a result of decreased are the most common initiating factors of glaucoma in cats axoplasmic flow or direct ischemia is uncertain (7). In general, (5,6). In uveitis, the source of the obstruction to aqueous humor cats show less severe changes than do other species exposed to outflow is often the accumulation of inflammatory infiltrates the same severity and duration of increased intraocular pres- at the iridocorneal angle (5,7), although this may not always sure (5,7). be observed histologically (3). Also, chemicals released during The menace response test can be helpful to detect vision, inflammation may damage the trabecular endothelial cells in but if severe buphthalmos has resulted in lagophthalmos and that area, impairing their ability to filter fluid out of the eye (7). difficulty closing the eyelids, the results may be inaccurate or Chronic inflammation can also result in the formation of a pre- subtle. As it is a learned response, kittens may not respond iridal fibrovascular membrane or synechiae that could contribute consistently to a menace response test until 4 mo of age. to the development of secondary glaucoma (3,5,7). Additionally, a pupillary light response test can be used. If the This kitten represents a major presentation of glaucoma opposite eye is unaffected, the presence of a consensual response in cats: glaucoma secondary to lympho-plasmacytic uveitis in that eye indicates retinal function in the affected eye. An

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electroretinogram (ERG) is a more definitive way to quantify age, and severity and duration of the problem, surgical manage- retinal function and may be used by veterinary ophthalmolo- ment by enucleation was the most appropriate approach in this gists in some cases. Cats, especially young kittens, may still have kitten. There are 2 major methods of enucleation: transpalpebral vision despite overt buphthalmos (3). and transconjunctival. For either surgery, care should be taken to Medical management of glaucoma in cats can be difficult, avoid pulling on the optic nerve since traction can damage the STUDENT PAPER STUDENT especially due to late presentation and drug restrictions com- optic chiasm and result in blindness in the unaffected eye. Both mon in this species (6). Most initially unaffected eyes eventu- techniques are common in practice and provide a permanent ally lose vision despite treatment. In a study of 82 cats, with surgical solution to a frustrating medical condition. medical management alone, 58% of cats were able to be kept Feline glaucoma is associated with a poor long-term prognosis comfortable (defined as IOP , 30 mmHg for blind eyes and for vision and comfort in the affected eye (3). Since medical , 25 mmHg for unaffected eyes in order to preserve retinal management can be costly and is often ultimately unsuccess- function), but less than half maintained vision long-term (2). ful, treatment should be considered on a case-by-case basis. A combination of drugs can be used to manage the condition, Secondary glaucoma can be cured surgically and cats tend to such as carbonic anhydrase inhibitors and beta blockers (4). adjust very well to the reduced vision. Topical steroids can be helpful in treating primary uveitis; however, steroid-induced ocular hypertension is also reported Acknowledgments and IOP monitoring is necessary (3). If inflammation extends I thank veterinary surgeon Laura Farrell for her expertise in into the posterior segment, then systemic anti-inflammatories this case and veterinary surgeon Gerry O’Dowd for hosting are required (7). Whenever possible, the inciting cause should me at O’Dowd Veterinary Hospital in Ireland for my extern- be determined and treated directly. ship. The entire staff was invaluable during my rotation. I also Surgical management of glaucoma aims at controlling pain thank Dr. Elena Riccardi, Veterinary Pathologist at IDEXX and reducing the need for medications. Drainage valve implants Laboratories, for providing histologic images and answering my and diode laser or cryotherapy can be used to help manage a many questions. CVJ visual eye, but are generally performed by an ophthalmologist and can exacerbate inflammation. Chemical ablation is a method References used to reduce fluid production from the ciliary body and retain 1. Gelatt KN, Gelatt JP. Veterinary Ophthalmic Surgery. Philadelphia, the eye. If successful it can increase comfort, but it is not recom- Pennsylvania: Elsevier Saunders, 2011:60–64. mended in cats due to an association with intraocular sarcoma 2. Blocker T, Van Der Woerdt A. The feline glaucomas: 82 cases (1995–1999). Vet Ophthalmol 2001;4:81–85. development in this species (7). If the eye is blind or painful, 3. McLellan GJ, Miller PE. Feline glaucoma — A comprehensive review. removal by enucleation or evisceration/prosthesis can help to Vet Ophthalmol 2011;14:15–29. increase comfort. Enucleation should be considered when there 4. Norsworthy GD, Crystal MA, Grace SF, Tilley LP. The Feline Patient. 3rd ed. Ames, Iowa: Blackwell Publishing, 2006:385–387. is a history of trauma to reduce the risk of intraocular sarcoma 5. Wilcock BP, Peiffer RL, Jr, Davidson MG. The causes of glaucoma development from inflammation (7). Evisceration with intraocu- in cats. Vet Pathol 1990;27:35–40. lar prosthesis can be performed for cosmesis; however, cats often 6. McLellan GJ, Teixeira LBC. Feline glaucoma. Vet Clin Small Anim Pract 2015;45:1307–1333. don’t respond well to the implants and often eventually need to 7. Gelatt KN, Gilger BC, Kern TJ. Veterinary Ophthalmology. 5th ed. have them removed (3,6). Due to financial restrictions, patient Ames, Iowa: Wiley-Blackwell, 2013:441–489, 1509–1518.

CVJ / VOL 58 / MARCH 2017 301 FOR PERSONAL USE ONLY Clinical education, communication and practice management skills ...surrounded by the beauty of the rocky mountains!

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FAIRMONT BANFF SPRINGS HOTEL BANFF, AB

• the CanWest Veterinary Conference has been • pre-conference wet labs will be offered on Friday, offering world class continuing education since 2004 October 13 in cooperation with the University of • CanWest continuing education registration Calgary, Faculty of Veterinary Medicine includes refreshment breaks, lunch and access • network with industry colleagues during the two- to the trade fair day trade fair featuring 90 booths • tracks run in the following areas, offering • join us for the popular Meet and Greet Social on something for all veterinary team members: Saturday, October 14 Companion Animal, Equine, Food Animal, • CanWest welcomes the AAAHT pre-conference Veterinary Team, Veterinary Technologist CE event and AGM on Saturday, October 14. • 2017 RACE approval pending Technologists are encouraged to attend!

REGISTER EARLY AND SAVE on individual registrations and clinic www.canwestconference.ca packages. Early bird rates in effect until SEPTEMBER 15. FOR PERSONAL USE ONLY Veterinary Practice Management Gestion d’une clinique vétérinaire

Chasing higher wages: Associate veterinarian compensation through the provinces À la recherche de salaires supérieurs : rémunération des vétérinaires salariés dans les provinces

Chris Doherty

n their search for the perfect job, it is not uncommon for an ors de la recherche de l’emploi idéal, il n’est pas rare qu’un I associate veterinarian to move among provinces. In a recent L vétérinaire salarié déménage d’une province à l’autre. Or, survey of new graduates, 53% indicated they would be willing dans un sondage récent auprès des finissants, 53 % ont indiqué to go to another province to secure employment. While fam- qu’ils seraient disposés à déménager dans une autre province ily, quality of life, or a multitude of other reasons can affect pour obtenir un emploi. Même si la famille, la qualité de vie ou the decision, compensation is often a significant part of the une multitude d’autres raisons peuvent affecter la décision, la motivation to move. However, comparing absolute compensa- rémunération est souvent un élément important dans la décision tion paints only half the picture; in order to make a more valid de déménager. Cependant, la comparaison de la rémunération comparison, the difference in the COL must be accounted for. absolue brosse seulement la moitié du tableau, car afin d’effectuer This topic has recently gained attention in other fields as une meilleure comparaison, nous devons tenir compte de la well, notably the technology sector, when comparing areas such différence du coût de la vie (CDV). as Silicon Valley to Kitchener-Waterloo. While incomes in the Ce sujet a récemment également attiré l’attention dans d’autres iconic California region are typically higher, the COL also dwarfs domaines, notamment dans le secteur de la technologie lorsque that of Kitchener-Waterloo, which may require a careful calcula- l’on compare des régions comme Silicon Valley et Kitchener- tion before an individual decides where to accept employment. Waterloo. Même si les salaires dans la région emblématique Data for this investigation is provided through the 2016 de la Californie sont habituellement supérieurs, le CDV est Provincial Surveys of Compensation and Benefits for Associate aussi vastement supérieur à celui de Kitchener-Waterloo, ce qui Veterinarians. Figures 1 and 2 present data for for full-time peut exiger un calcul minutieux avant qu’une personne décide associate veterinarians employed in private practice. d’accepter un emploi. In addition to presenting the median compensation, cost of Les données de cette enquête sont fournies dans le cadre des living (COL)-adjusted median compensation is included. The Sondages provinciaux 2016 sur la rémunération des vétérinaires benefit to including Figure 2 is that it accounts for variation in salariés. Les figures 1 et 2 présentent les données pour les how much it costs to reside in each province. For example, a vétérinaires salariés à temps plein travaillant en pratique privée.

Dr. Doherty is a graduate of the Ontario Veterinary College and he works as an economic analyst for the Ontario Veterinary Medical Association. This article is provided as part of the CVMA Business Management Program, which is co-sponsored by IDEXX Laboratories, Petsecure Pet Health Insurance, Merck Animal Health, and Scotiabank. Address all correspondence to the CVMA Business Management Committee; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. Le Dr Doherty est diplômé de l’Ontario Veterinary College et travaille en tant qu’analyste économique pour l’Ontario Veterinary Medical Association. Le présent article est rédigé dans le cadre du Programme de gestion commerciale de l’ACMV, qui est cocommandité par IDEXX Laboratories, Petsecure Insurance, Merck Santé Animale et la Banque Scotia. Veuillez adresser toute correspondance au Comité de la gestion commerciale de l’ACMV; courriel : [email protected] L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.

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$88 500 $85 000 $82 000 $81 000 $82 250 $80 284 $78 000 $74 000 $70 000 $70 000 $70 000

GESTION D’UNECLINIQUE VÉTÉRINAIRE Canada BC AB SK MB ON QC NB NS PE NL C.-B. Alb. Sask. Man. Ont. N.-B. N.-É. Î.-P.-É. T.-N.-L. Figure 1. Median annual compensation for full-time associate veterinarians employed in private practice, stratified by province. BC — British Columbia; AB — Alberta; SK — Saskatchewan; MB — Manitoba; ON — Ontario; QC — Quebec; NB — New Brunswick; NS — Nova Scotia; PE — Prince Edward Island; NL — Newfoundland and Labrador./Rémunération médiane annuelle des vétérinaires salariés à temps plein travaillant en pratique privée, stratifiée selon la province. C.-B. — Colombie-Britannique; Alb. — Alberta; Sask. — Saskatchewan; Man. — Manitoba; Ont. — Ontario; QC — Québec; N.-B. — Nouveau-Brunswick; N.-É. — Nouvelle-Écosse; Î.-P.-É. — Île-du-Prince-Édouard; T.-N.-L. — Terre-Neuve-et-Labrador. $88 725 $85 551 $86 309 $81 951 $82 316 $82 667 $80 284 $78 666 $80 154 $73 685 $70 767

Canada BC AB SK MB ON QC NB NS PE NL C.-B. Alb. Sask. Man. Ont. N.-B. N.-É. Î.-P.-É. T.-N.-L. Figure 2. Cost of living (COL)-adjusted median annual compensation for full-time associate veterinarians employed in private practice, stratified by province. BC — British Columbia; AB — Alberta; SK — Saskatchewan; MB — Manitoba; ON — Ontario; QC — Quebec; NB — New Brunswick; NS — Nova Scotia; PE — Prince Edward Island; NL — Newfoundland and Labrador./La rémunération médiane annuelle ajustée au coût de la vie (CDV) des vétérinaires travaillant à temps plein en pratique privée, stratifiée selon la province. C.-B. — Colombie-Britannique; Alb. — Alberta; Sask. — Saskatchewan; Man. — Manitoba; Ont. — Ontario; QC — Québec; N.-B. — Nouveau-Brunswick; N.-É. — Nouvelle-Écosse; Î.-P.-É. — Île-du-Prince-Édouard; T.-N.-L. — Terre-Neuve-et-Labrador.

family living in Alberta is likely to have much higher monthly En plus de présenter la rémunération médiane, la rémunération expenses compared to one in Prince Edward Island, despite médiane ajustée en fonction du coût de vie (CDV) est aussi maintaining a similar standard of living. incluse. L’avantage d’inclure la figure 2 est qu’elle tient compte Figures 1 and 2 outline the median annual compensation for des variations du coût du logement dans chaque province. Par full-time associate veterinarians in each province, as well as the exemple, une famille habitant en Alberta aura probablement COL-adjusted median annual compensation. des dépenses mensuelles beaucoup plus élevées que celles à In comparing median annual compensation, the top paying l’Île-du-Prince-Édouard, malgré un niveau de vie semblable. provinces likely come as no surprise; Alberta leads the way with Les figures 1 et 2 illustrent la rémunération annuelle médiane a median of $88 500, followed by Newfoundland and Labrador des vétérinaires salariés à temps plein dans chaque province ainsi at $85 000. Ontario and British Columbia are not far behind, que la rémunération annuelle médiane ajustée au coût de la vie. at medians of $82 250 and $82 000, respectively. The Maritime Lors de la comparaison de la rémunération médiane annuelle, Provinces, excluding Newfoundland and Labrador, all had a il n’est pas surprenant de constater les provinces qui se trouvent median compensation of $70 000, the lowest in Canada. en tête de liste : l’Alberta mène le classement avec une médiane

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Saguenay * VETERINARY PRACTICE MANAGEMENT VETERINARY Trois-Rivières * St. John’s * Greater Sudbury * Québec * Saint John * Sherbrooke * Thunder Bay * Moncton Ottawa–Gatineau* Saskatoon Kelowna Montréal Canada Halifax Oshawa Calgary London Regina Kingston St. Catharines–Niagara Hamilton * Brantford Winnipeg * Abbotsford–Madison Kitchener–Cambridge–Waterloo * Peterborough Victoria * Barrie * Edmonton * Guelph * Windsor * Toronto * Vancouver *

7.6 7.7 7.8 7.9 8 8.1 8.2 8.3 8.4

Figure 3. Average life satisfaction across census metropolitan areas, 2009 to 2013. * indicates that the census metropolitan area (CMA) average is significantly different from the Canadian average (P , 0.05). Note: the horizontal error lines overlaid on the bars indicate the 95% confidence intervals (CIs). Confidence intervals indicate the degree of variability in the estimate and enable more valid comparisons of differences between estimates. Sources: Statistics Canada, General Social Survey, 2009 to 2013, and Canadian Community Health Survey, 2009 to 2012./Satisfaction moyenne à l’égard de la vie dans les régions métropolitaines de recensement, de 2009 à 2013. * Indique que la moyenne de la région métropolitaine de recensement (RMC) affiche un écart important avec la moyenne canadienne (P , 0,05). Nota : les lignes d’erreur horizontales superposées sur les traits indiquent des intervalles de confiance (IC) de 95 %. Les intervalles de confiance indiquent le degré de variabilité de l’estimation et permettent de meilleures comparaisons des différences entre les estimations. Sources : Statistique Canada, Enquête sociale générale, 2009 à 2013, et Enquête sur la santé dans les collectivités canadiennes, 2009 à 2012.

After including COL in the equation, the results change de 88 500 $, suivie de Terre-Neuve-et-Labrador avec 85 000 $. dramatically, with the Maritime Provinces becoming far more L’Ontario et la Colombie-Britannique ne sont pas loin derrière, attractive to associate veterinarians. Newfoundland and Labrador avec des médianes de 82 250 $ et de 82 000 $, respectivement. now becomes the highest paying province, with a median annual Les provinces maritimes, à l’exclusion de Terre-Neuve-et-Labrador, compensation of $88 725, while Quebec is a close second at affichaient toutes une rémunération médiane de 70 000 $, soit la $86 309. Previously high paying provinces such as Alberta and plus faible au Canada. Ontario drop down the rankings, with COL-adjusted median Après l’inclusion du CDV dans l’équation, les résultats annual compensations of $70 767 and $78 666, respectively. changent considérablement, et les provinces maritimes

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However, as mentioned, there are a plethora of reasons an Notes: Median annual compensation was determined using individual may move to a new province. Compensation is one, the 2016 Provincial Surveys of Compensation and Benefits for but quality of life can also be very important. Associate Veterinarians. Cost of living-adjusted median annual In 2015, Statistics Canada published a report on Canadians’ compensation was determined through use of the most recent life satisfaction, in which they asked respondents to rate how Statistics Canada data on average household expenditures, by they feel about their life as a whole, on a scale of 1 to 10 (with province. The average household expenditure in each province 10 being “very satisfied”) (Figure 3). The results were then bro- was divided by the average household expenditure of the nation ken down by census metropolitan area, to see exactly which parts as a whole, to determine the province to nation ratio. This ratio of the country had the highest levels of life satisfaction. Overall, was then multiplied by the median annual compensation in Canadians had an average life satisfaction of 7.97. Saguenay and each province (as determined by the results of each respective Trois-Rivières lead the pack, with average life satisfactions of Provincial Survey of Compensation and Benefits for Associate 8.24 and 8.18, respectively. Meanwhile, Vancouver and Toronto Veterinarians), to determine the COL-adjusted median annual were at the bottom of the list, with average life satisfactions of compensation in each province. Information regarding percent- 7.81 and 7.82, respectively. age of new graduates willing to leave the province to secure Analyzing the COL-adjusted median annual compensation employment was determined using the OVMA 2015 Survey of GESTION D’UNECLINIQUE VÉTÉRINAIRE in combination with the results of Statistics Canada’s life satis- New Graduates. ■ faction survey, it becomes obvious: for associate veterinarians http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/ seeking high compensation and a good quality of life, move to famil130a-eng.htm Quebec. http://www.statcan.gc.ca/pub/11-626-x/11-626-x2015046- eng.htm

deviennent beaucoup plus attrayantes pour les vétérinaires salariés. satisfaction à l’égard de la vie de Statistique Canada, il devient Terre-Neuve-et-Labrador devient maintenant la province affichant évident que les vétérinaires salariés qui sont à la recherche d’une la rémunération la plus importante, avec une rémunération rémunération élevée et d’une bonne qualité de vie déménagent annuelle de 88 725 $, tandis que le Québec suit de près en au Québec. deuxième place avec 86 309 $. Les provinces qui affichaient précédemment des salaires élevés, comme l’Alberta et l’Ontario, Notes : La rémunération médiane annuelle a été déterminée en chutent dans le classement, avec des rémunérations médianes utilisant les Sondages provinciaux 2016 sur la rémunération et annuelles ajustées pour le CDV de 70 767 $ et de 78 666 $, les avantages sociaux des vétérinaires salariés. La rémunération respectivement. médiane annuelle ajustée au coût de la vie a été déterminée en Cependant, tel qu’il a été mentionné, il y a des foules de utilisant les données de Statistique Canada les plus récentes sur raisons pour lesquelles une personne déménage dans une nouvelle les dépenses moyennes des ménages, par province. Les dépenses province. La rémunération représente une raison, mais la qualité moyennes par ménage dans chaque province ont été divisées de la vie peut aussi occuper une place importante. par les dépenses moyennes par ménage pour le pays en entier En 2015, Statistique Canada a publié un rapport sur la afin de déterminer le ratio de la province par rapport au pays. satisfaction à l’égard de la vie des Canadiens, dans lequel on a Ce ratio a ensuite été multiplié par la rémunération médiane demandé aux répondants d’évaluer leur satisfaction à l’égard annuelle dans chaque province (déterminée dans chacun des de leur vie en général, sur une échelle de 1 à 10 (10 étant Sondages provinciaux sur la rémunération et les avantages sociaux «très satisfait(e)» (figure 3). Les résultats ont ensuite été répartis des vétérinaires salariés), afin de déterminer la rémunération selon la région métropolitaine de recensement, pour voir médiane annuelle ajustée au CDV dans chaque province. Les exactement quelles régions du pays affichaient les plus hauts renseignements concernant le pourcentage de finissants disposés niveaux de satisfaction à l’égard de la vie. Dans l’ensemble, les à quitter la province pour obtenir un emploi a été déterminée Canadiens avaient une satisfaction moyenne à l’égard de la vie en utilisant le Sondage auprès des finissants 2005 réalisé par de 7,97. Le Saguenay et Trois-Rivières menaient le peloton, l’OVMA. ■ avec des satisfactions moyennes à l’égard de la vie de 8,24 et de http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/ 8,18 respectivement, tandis que Vancouver et Toronto se situaient famil130a-fra.htm au bas de la liste, avec des satisfactions moyennes à l’égard de la vie de 7,81 et de 7,82, respectivement. http://www.statcan.gc.ca/pub/11-626-x/11-626-x2015046-fra. En analysant la rémunération médiane annuelle ajustée htm au CDV en combinaison avec les résultats du sondage sur la

306 CVJ / VOL 58 / MARCH 2017 FOR PERSONAL USE ONLY Diagnostic Ophthalmology Ophtalmologie diagnostique

Lynne S. Sandmeyer, Marina L. Leis, Bianca S. Bauer History and clinical signs What are your clinical diagnoses, 9-year-old spayed female domestic shorthaired cat was exam- differential diagnoses, therapeutic plan, Ained at the ophthalmology service at the Western College of and prognosis? Veterinary Medicine. This cat was presented because of irregularly Discussion shaped pupils which had been present since being adopted 6 y pre- The clinical diagnoses were uveal cysts, secondary glaucoma, viously. Over the last year she had developed mild blepharospasm and incipient cataract of both eyes. Uveal cysts are reported in and clear ocular discharge. The menace responses, and palpebral, many species (1–5). Uveal cysts are fluid-filled structures arising occulocephalic, direct and consensual pupillary light reflexes were from the posterior iris or ciliary body epithelia. They may be present bilaterally. Schirmer tear test (Schirmer Tear Test Strips; unilateral or bilateral, single or multiple, variably sized, and are Alcon Canada, Mississauga, Ontario) values were 19 mm/min usually spherical, oval, or elongated. They may be free-floating bilaterally. The intraocular pressures were estimated with a rebound or remain attached to the uvea and may be variably pigmented tonometer (Tonvet; Tiolat, Helsinki, Finland) prior to mydriasis (2). In cats, the most common location for cysts is the ventral and were 33 and 29 mmHg in the right and left eyes, respec- pupillary margin, followed by multiple cysts distributed around tively. Fluorescein staining (Fluorets; Bausch & Lomb Canada, the pupil and the medial pupillary margin (1). Lens capsule Markham, Ontario) was negative bilaterally. On direct examina- and corneal endothelial pigment dispersion may occur if cysts tion there were darkly pigmented round to oval masses projecting rupture, collapse, or contact these surfaces. from the posterior chamber and causing displacement of the iris The differential diagnosis for a uveal mass is melanocytic anteriorly. Following application of 0.5% tropicamide (Mydriacyl; neoplasia. Cysts are fluid-filled and can be distinguished from Alcon Canada, Mississauga, Ontario) biomicroscopic examination solid masses when using a bright light source as cysts are easily (Osram 64222; Carl Zeiss Canada, Don Mills, Ontario) revealed transillmuniated. Ocular ultrasound can also be used to detect nuclear sclerosis and anterior cortical incipient cataract in both the presence of fluid in a densely pigmented cyst that does not lenses. The masses could be transilluminated indicating they easily transilluminate. were fluid-filled. Indirect ophthalmoscopic (Heine Omega 200; There may be a genetic predilection in the Burmese as this Heine Instruments Canada, Kitchener, Ontario) examination did breed accounted for 21/36 cats affected with uveal cysts in a not reveal abnormalities in either eye. Intraocular pressures were recent retrospective study consistent with a significant risk ratio re-measured after mydriasis and were 45 and 50 mmHg in the of 12.2 compared to the non-Burmese population. The mean right and left eyes, respectively. A photograph of the right and left age of cats presenting with uveal cysts was 10.25 y and females eyes at presentation is provided for your assessment (Figure 1). accounted for the majority of cases (23/36) (1).

Figure 1. Photograph of the right and left eyes of a 9-year-old domestic shorthaired cat following pharmacologic mydriasis.

Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, Saskatchewan S7N 5B4. Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

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Uveal cysts may be congenital or acquired. Acquired cysts refractory to medical therapy. Use of transcorneal semiconductor may develop spontaneously; however, trauma and intraocular diode laser is an effective, non-invasive, method of deflation and inflammation are also suggested as possible causes (2). Although photocoagulation of cysts employed by veterinary ophthalmolo- the exact pathogenesis of uveal cysts is not known, cysts usually gists (5). Immediate postoperative reduction of intraocular pres- arise from the posterior epithelial layers of the iris or ciliary sure was reported in cats treated with this modality (5). Due to body and may develop due to a failure of adhesion between the mild elevation of intraocular pressure in this cat, therapy was the inner and outer layers of the embryologic optic cup (3). initiated with topical dorzolamide hydrochloride 2%/timolol As the posterior iris epithelium is darkly pigmented, this likely maleate 0.5% (Cosopt; Merk Frosst Canada, Kirkland, Quebec), accounts for the dark brown appearance of cysts arising from the q8h. The owners were instructed to return for re-evaluation in iris, compared to more translucent cysts arising from the ciliary 7 to 10 d; however, they declined to return and the cat was lost body which has a non-pigmented outer epithelium. to follow-up. Concurrent ocular disease is uncommon in cats with uveal The prognosis for uveal cysts in cats is good. Small cysts cysts (1). In dogs, a syndrome of uveal cysts, uveitis, and sec- do not generally interfere with vision; however, extensive cyst ondary glaucoma, known as pigmentary uveitis is reported in formation may impair vision in some animals when the pupil OPHTALMOLOGIE DIAGNOSTIQUE OPHTALMOLOGIE some breeds (2,6,7). This condition is most commonly recog- is miotic. Anterior displacement of cysts may impair aque- nized in the golden retriever and is suspected to be heritable ous humor outflow resulting in elevated intraocular pressure (7). Although a similar syndrome is not recognized in the cat, which can be exacerbated by pharmacological dilation of the elevation of intraocular pressure may occur related to multiple iris. Treatment with topical antiglaucoma medications and uveal cysts. The cat in the present case had a mild elevation non-invasive diode laser disruption of uveal cysts is effective of intraocular pressure in 1 eye and high-normal intraocular in most cats. pressure in the other at presentation which became more References pronounced following mydriasis. Blacklock et al (1) reported 1. Blacklock BT, Grundon RA, Meehan M, Tetas Pont R, Hartley C. Uveal a similar unilateral IOP elevation in 1 of 36 cats in which cysts in domestic cats: A retrospective evaluation of thirty-six cases. Vet the pre-dilation intraocular pressure was 31 mmHg; however, Ophthalmol 2016;9:56–60. post-dilation data were not available. Gemensky-Metzler et al 2. Hendrix DVH. Disease and surgery of the canine anterior uvea. In: Gelatt KN, Gilger BC, Kern TJ, eds. Veterinary Ophthalmology. 5th ed. Ames, (5) reported elevation of intraocular pressure in all cats follow- Iowa: Wiley-Blackwell Publishing, 2013:1146–1198. ing mydriasis with the mean intraocular pressure increasing 3. Cook CS. Ocular embryology and congenital malformation. In: Gelatt from 19.5 to 24.6 mmHg. Elevation of intraocular pressure is KN, Gilger BC, Kern TJ, eds. Veterinary Ophthalmology. 5th ed. Ames, Iowa: Wiley-Blackwell Publishing, 2013:28 p. thought to be related to anterior displacement of the iris causing 4. Belkin PV. Iris cysts in cats. Fel Pract 1983;13:12–18. obstruction of the iridocorneal angle and/or leading to collapse 5. Gemensky-Metzler AJ, Wilkie DA, Cook CS. The use of semiconductor of the ciliary cleft. diode laser for deflation and coagulation of anterior uveal cysts in dogs, cats and horses: A report of 20 cases. Vet Ophthalmol 2004;7:360–368. Elevation of intraocular pressure may be treated with topical 6. Sapienza JS, Simo FJ, Prades-Sapienza A. Golden retriever uveitis: antiglaucoma therapy: use of twice daily dorzolamide-timolol 75 cases (1994–1999). Vet Ophthalmol 2000;3:241–246. was reported to successfully reduce the intraocular pressure in 7. Holly VL, Sandmeyer LS, Bauer BS, Verges L, Grahn BH. Golden retriever cystic uveal disease: A longitudinal study of uveal cysts, pigmen- cats (1). Definitive treatment of cysts may be necessary if they tary uveitis, and pigmentary/cystic glaucoma over a decade in Western are impeding vision or causing intraocular pressure elevations Canada. 2016;19:237–244.

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